31 Mar 2025 Abu RAHMAN · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Lack of awareness of opioid toxicity and accumulation risks in patients with kidney impairment or failure View source Failure to ensure timely availability of Naloxone View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Abu RAHMAN · 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
Abu Rahman, aged 88, suffered a traumatic fall causing a fractured hip and underwent hemi-arthroplasty before deteriorating with pneumonia on a background of end stage renal failure. Concerns included delays in obtaining Naloxone when supplies ran out and limited awareness of opioid toxicity or accumulation in patients with kidney impairment or failure.
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 Royal Free Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of opioid toxicity and accumulation risks in patients with kidney impairment or failure
Wider context from the report “Firstly, I heard evidence from the family that nursing staff were frequently unable to administer Naloxone as it had run out. They had to obtain more Naloxone from the pharmacy, which led to delays for “hours and hours” on multiple occasions.
Secondly, I heard evidence concerning a lack of awareness or appreciation concerning the risk of opioid toxicity / accumulation in patients with kidney impairment/failure, even where the “correct” dose may have been given .
I am concerned that if there is no proper or properly implemented system for obtaining medication in a timely manner, and limited awareness of the matters canvassed above , then this gives rise to a risk of future deaths.
” 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 Royal Free Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure timely availability of Naloxone
Wider context from the report “Firstly, I heard evidence from the family that nursing staff were frequently unable to administer Naloxone as it had run out . They had to obtain more Naloxone from the pharmacy, which led to delays for “hours and hours” on multiple occasions .
Secondly, I heard evidence concerning a lack of awareness or appreciation concerning the risk of opioid toxicity / accumulation in patients with kidney impairment/failure, even where the “correct” dose may have been given.
I am concerned that if there is no proper or properly implemented system for obtaining medication in a timely manner , and limited awareness of the matters canvassed above, then this gives rise to a risk of future deaths.
” Open source report
13 Mar 2025 Billie Diane WICKS · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 6 Understaffing of the emergency department, including insufficient staff to take basic observations View source Failure to perform hourly observations in the emergency department View source Failure to administer the first antibiotic dose in the emergency department View source Lack of training or guidance on adult-onset asthma View source Safety-netting advice failing to provide a meaningful instruction when patients have already sought help for the same concern View source Failure to include blood pressure in the national paediatric early warning score View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Billie Diane WICKS · 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
Billie Wicks, aged 16, was brought to hospital with an asthma attack and was discharged without adequate repeat observations or senior clinical review. The report states that her asthma was not diagnosed or treated and that she died from infective exacerbation of asthma. Concerns included understaffing and inadequate observations, delayed antibiotic treatment, lack of awareness of adult-onset asthma, and the limitations of safety-netting advice after her parents had already sought hospital care.
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 Royal Free Hospital; that does not assign responsibility.
PFD Monitor interpretation Understaffing of the emergency department, including insufficient staff to take basic observations
Wider context from the report “1. At inquest, I heard repeatedly that on the night Billie attended, the Royal Free emergency department was understaffed, and that it remains understaffed of doctors, nurses, and even a healthcare assistant who could take basic observations .
Billie should have had observations every hour. If she had had these observations, the emergency registrar who discharged her would have recognised that she was not as well as he thought, and would have sought senior medical review. That senior medical review would have changed the course of her management and saved her life.
Following the inquest touching on the death of Daniel Klosi, I wrote to you on 16 August 2024 about a lack of observations in the emergency department of the Royal Free. Although the circumstances were different, there is a theme.
” 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 Royal Free Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to perform hourly observations in the emergency department
Wider context from the report “1. At inquest, I heard repeatedly that on the night Billie attended, the Royal Free emergency department was understaffed, and that it remains understaffed of doctors, nurses, and even a healthcare assistant who could take basic observations.
Billie should have had observations every hour . If she had had these observations, the emergency registrar who discharged her would have recognised that she was not as well as he thought, and would have sought senior medical review. That senior medical review would have changed the course of her management and saved her life.
Following the inquest touching on the death of Daniel Klosi, I wrote to you on 16 August 2024 about a lack of observations in the emergency department of the Royal Free . Although the circumstances were different, there is a theme.
” 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 Royal Free Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to administer the first antibiotic dose in the emergency department
Wider context from the report “2. The registrar who saw Billie the night before her death prescribed an antibiotic, but he was not in the habit of giving the first dose in the department and he did not on this occasion . This meant that Billie’s infection was not tackled as quickly as it could have been. This seems to indicate a training and potentially a guideline need.
” 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 Royal Free Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of training or guidance on adult-onset asthma
Wider context from the report “3. At the time of Billie’s presentation, the registrar was unaware of the possibility of adult onset asthma . This seems to indicate a training and potentially a guideline need .
” 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 Royal Free Hospital; that does not assign responsibility.
PFD Monitor interpretation Safety-netting advice failing to provide a meaningful instruction when patients have already sought help for the same concern
Wider context from the report “4. I heard that Billie was safely netted when she was discharged. Her parents were told to bring her back if they had any concerns.
I have heard this safety netting advice being described many, many times in different inquests. What worries me about it in this context is that Billie’s parents had brought her to hospital because they were concerned. They were then reassured by hospital staff. It is therefore difficult to see how this particular advice could be a meaningful instruction.
In reality, her parents’ initial concern was well placed and they had responded to it appropriately by bringing Billie to hospital. When Billie began to deteriorate again, her parents’ natural instinct had been blunted by their first visit to the hospital.
” 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 Royal Free Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to include blood pressure in the national paediatric early warning score
Wider context from the report “5. Whilst I doubt that it would have made a difference in this case, I understand that blood pressure is not yet an observation included in the national paediatric early warning score (PEWS) .
” Open source report
11 Feb 2025 John Tompkins · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Limited internal review of procedure-related circumstances View source Failure to consider NatSSIPS2 standards in detail during internal review View source Failure to consider NatSSIPS2 standards when undertaking procedures View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
John Tompkins · 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
John Tompkins died on 25 July 2024 after hepatic artery embolisation and right-sided portal vein embolisation were undertaken simultaneously rather than sequentially. He subsequently developed acute-on-chronic liver failure and died from consequential multiorgan failure. Concerns included limited internal review of the circumstances and the Trust’s apparent failure to consider NatSSIPS2 standards when undertaking or reviewing the procedures.
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 Royal Free Hospital; that does not assign responsibility.
PFD Monitor interpretation Limited internal review of procedure-related circumstances
Wider context from the report “1. I am concerned that there was limited internal review of the circumstances of Mr Tompkins’ death , following identification that the procedures were undertaken at the same time;
2. Further and linked to the above, I am concerned that the Trust seemingly did not consider the NatSSIPS2 standards either when undertaking the procedures, nor in detail as part of its review following the inquest.
” 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 Royal Free Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to consider NatSSIPS2 standards in detail during internal review
Wider context from the report “1. I am concerned that there was limited internal review of the circumstances of Mr Tompkins’ death, following identification that the procedures were undertaken at the same time;
2. Further and linked to the above, I am concerned that the Trust seemingly did not consider the NatSSIPS2 standards either when undertaking the procedures, nor in detail as part of its review following the inquest .
” 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 Royal Free Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to consider NatSSIPS2 standards when undertaking procedures
Wider context from the report “1. I am concerned that there was limited internal review of the circumstances of Mr Tompkins’ death, following identification that the procedures were undertaken at the same time;
2. Further and linked to the above, I am concerned that the Trust seemingly did not consider the NatSSIPS2 standards either when undertaking the procedures , nor in detail as part of its review following the inquest.
” Open source report
14 Aug 2024 Daniel KLOSI · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Failure to explicitly emphasise prompt escalation when observations cannot be obtained View source Emergency department electronic patient records failing to show repeat presentations during the current illness View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Daniel KLOSI · 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
Daniel died on his fourth presentation in a week to the Royal Free Hospital, with group A streptococcus sepsis recorded as the medical cause of death. Concerns included the delay in obtaining a full set of observations when he was distressed, and electronic records not showing how many times a patient had attended hospital with the same signs and symptoms during the current illness.
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 Royal Free Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to explicitly emphasise prompt escalation when observations cannot be obtained
Wider context from the report “1. It was difficult for the nursing staff to obtain Daniel’s observations because he was so distressed. That was understandable, but because of the long wait in a busy department, it meant that on the fourth attendance Daniel did not have a full set of observations for over four hours and shortly afterwards suffered a catastrophic cardiovascular compromise.
I heard that obtaining no observations should be regarded in the same light as obtaining worrying observations, and should be escalated without delay .
It seems that this has not been emphasised explicitly to nursing and medical staff at the trust – and obviously may not have been in other trusts.
” 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 Royal Free Hospital; that does not assign responsibility.
PFD Monitor interpretation Emergency department electronic patient records failing to show repeat presentations during the current illness
Wider context from the report “2. The trust emergency department electronic patient records do not show how many times a patient has presented to hospital with the same signs and symptoms during their current illness – and of course this may be the case in other emergency departments.
” Open source report
12 Jul 2021 Stephen Francis WALKER · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 5 Medical records that are confusing and difficult for consultants to read View source Failure to pass a nasogastric tube when clinically indicated View source Failure to document whether nasogastric tube placement was offered and declined View source Failure to ensure timely medical review after deterioration and repeated requests View source Lack of documented abdominal examination during ward review View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Stephen Francis WALKER · 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
Stephen Francis Walker was admitted for an ileostomy reversal and developed vomiting and severe illness several days later. A nasogastric tube was not placed until that evening, and he died the following day after admission to intensive care. Concerns included delayed assessment and treatment, inadequate or missing records of clinical reviews and consent, and confusing medical records; the inquest found that earlier tube placement would have improved his chance of survival.
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 Royal Free Hospital; that does not assign responsibility.
PFD Monitor interpretation Medical records that are confusing and difficult for consultants to read
Wider context from the report “4. At inquest, I asked the colorectal surgeon with care of Dr Walker to check matters in the online medical records before him. However, he said that he was in difficulty because they were so confusing in the way that they were laid out and completed .
If the records are so confusing that a consultant cannot read them easily , then that is obviously sub optimal in terms of care.
” 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 Royal Free Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to pass a nasogastric tube when clinically indicated
Wider context from the report “1. Dr Walker’s condition had deteriorated by the time of the morning ward round on Easter Monday, 5 April 2021. He said that he felt awful and had begun vomiting. Dr Walker wondered if this was secondary to opiate analgesia, and this was recorded as the clinical impression.
However, no record was put before me at inquest indicating that the clinical fellow undertaking the ward round conducted an abdominal examination, no subsequent early medical review was fixed and no nasogastric tube was passed .
2. At the morbidity and mortality meeting on 24 June, the registrar said that Dr Walker was offered a nasogastric tube but declined. However, I was told at inquest that there was no record of this.
3. I was told at inquest that, at lunch time on 5 April, nurses twice bleeped for a medical review, but there was no record that a medical review was undertaken, or that this was chased.
” 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 Royal Free Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to document whether nasogastric tube placement was offered and declined
Wider context from the report “1. Dr Walker’s condition had deteriorated by the time of the morning ward round on Easter Monday, 5 April 2021. He said that he felt awful and had begun vomiting. Dr Walker wondered if this was secondary to opiate analgesia, and this was recorded as the clinical impression.
However, no record was put before me at inquest indicating that the clinical fellow undertaking the ward round conducted an abdominal examination, no subsequent early medical review was fixed and no nasogastric tube was passed.
2. At the morbidity and mortality meeting on 24 June, the registrar said that Dr Walker was offered a nasogastric tube but declined. However, I was told at inquest that there was no record of this .
3. I was told at inquest that, at lunch time on 5 April, nurses twice bleeped for a medical review, but there was no record that a medical review was undertaken, or that this was chased.
” 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 Royal Free Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure timely medical review after deterioration and repeated requests
Wider context from the report “1. Dr Walker’s condition had deteriorated by the time of the morning ward round on Easter Monday, 5 April 2021. He said that he felt awful and had begun vomiting. Dr Walker wondered if this was secondary to opiate analgesia, and this was recorded as the clinical impression.
However, no record was put before me at inquest indicating that the clinical fellow undertaking the ward round conducted an abdominal examination, no subsequent early medical review was fixed and no nasogastric tube was passed.
2. At the morbidity and mortality meeting on 24 June, the registrar said that Dr Walker was offered a nasogastric tube but declined. However, I was told at inquest that there was no record of this.
3. I was told at inquest that, at lunch time on 5 April, nurses twice bleeped for a medical review, but there was no record that a medical review was undertaken, or that this was chased .
” 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 Royal Free Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of documented abdominal examination during ward review
Wider context from the report “1. Dr Walker’s condition had deteriorated by the time of the morning ward round on Easter Monday, 5 April 2021. He said that he felt awful and had begun vomiting. Dr Walker wondered if this was secondary to opiate analgesia, and this was recorded as the clinical impression.
However, no record was put before me at inquest indicating that the clinical fellow undertaking the ward round conducted an abdominal examination , no subsequent early medical review was fixed and no nasogastric tube was passed.
2. At the morbidity and mortality meeting on 24 June, the registrar said that Dr Walker was offered a nasogastric tube but declined. However, I was told at inquest that there was no record of this.
3. I was told at inquest that, at lunch time on 5 April, nurses twice bleeped for a medical review, but there was no record that a medical review was undertaken, or that this was chased.
” Open source report
5 Jan 2021 Hariharan Harichandra · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 7 Failure by staff to properly review Falls Assessment Tools View source Failure of scan-review systems to ensure review of all scans by a second clinician View source Failure to properly complete Falls Assessment Tools View source Failure to record severe adverse reactions to Naso-Gastric tube insertion View source Failure to properly explain CT scan interpretation errors View source Lack of training for hospital staff in assessing and managing externally provided equipment and its safety features View source Failure by Consultant Radiologists to identify clear and obvious neck fractures on CT scans View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Hariharan Harichandra · 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
Hariharan Harichandra, a 65-year-old man, fell from an electric wheelchair in hospital on 5 December 2019, sustaining a neck fracture, and died at The Royal Free Hospital on 19 December 2019. The concerns included errors in reporting and reviewing the CT scan, incomplete falls assessment, insufficient consideration of wheelchair safety equipment and spinal condition, and failure to record a severe adverse reaction to a naso-gastric tube.
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 Royal Free Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure by staff to properly review Falls Assessment Tools
Wider context from the report “I am concerned that:
(a) The error by the original clinician who interpreted the CT scan images of 5th December 2019 has not been properly explained.
(b) The Consultant Radiologist who reviewed the CT scan images of the 5th December 2019 should have noticed the clear and obvious neck fracture. Although there were 2 scans of the 5th December 2019 to review, it appeared that the clinician most probably reviewed only one of them. There ought to be a system in place when ensuring that a scan review can only be completed if all the scans taken are reviewed by a second clinician.
(c) The Falls Assessment Tool was not properly completed or reviewed by staff;
(d) Hospital staff have no training in how to assess and deal with private equipment brought from outside such as an electric wheelchair and the safety features of such devices;
(e) By hospital staff not recording Mr Harichandra’s adverse reaction to the Naso-Gastric tube insertion, future clinicians would have been unaware of this severe reaction when treating him and considering how his important nutritional needs should be met had he survived.
” 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 Royal Free Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of scan-review systems to ensure review of all scans by a second clinician
Wider context from the report “I am concerned that:
(a) The error by the original clinician who interpreted the CT scan images of 5th December 2019 has not been properly explained.
(b) The Consultant Radiologist who reviewed the CT scan images of the 5th December 2019 should have noticed the clear and obvious neck fracture. Although there were 2 scans of the 5th December 2019 to review, it appeared that the clinician most probably reviewed only one of them . There ought to be a system in place when ensuring that a scan review can only be completed if all the scans taken are reviewed by a second clinician .
(c) The Falls Assessment Tool was not properly completed or reviewed by staff;
(d) Hospital staff have no training in how to assess and deal with private equipment brought from outside such as an electric wheelchair and the safety features of such devices;
(e) By hospital staff not recording Mr Harichandra’s adverse reaction to the Naso-Gastric tube insertion, future clinicians would have been unaware of this severe reaction when treating him and considering how his important nutritional needs should be met had he survived.
” 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 Royal Free Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to properly complete Falls Assessment Tools
Wider context from the report “I am concerned that:
(a) The error by the original clinician who interpreted the CT scan images of 5th December 2019 has not been properly explained.
(b) The Consultant Radiologist who reviewed the CT scan images of the 5th December 2019 should have noticed the clear and obvious neck fracture. Although there were 2 scans of the 5th December 2019 to review, it appeared that the clinician most probably reviewed only one of them. There ought to be a system in place when ensuring that a scan review can only be completed if all the scans taken are reviewed by a second clinician.
(c) The Falls Assessment Tool was not properly completed or reviewed by staff;
(d) Hospital staff have no training in how to assess and deal with private equipment brought from outside such as an electric wheelchair and the safety features of such devices;
(e) By hospital staff not recording Mr Harichandra’s adverse reaction to the Naso-Gastric tube insertion, future clinicians would have been unaware of this severe reaction when treating him and considering how his important nutritional needs should be met had he survived.
” 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 Royal Free Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to record severe adverse reactions to Naso-Gastric tube insertion
Wider context from the report “I am concerned that:
(a) The error by the original clinician who interpreted the CT scan images of 5th December 2019 has not been properly explained.
(b) The Consultant Radiologist who reviewed the CT scan images of the 5th December 2019 should have noticed the clear and obvious neck fracture. Although there were 2 scans of the 5th December 2019 to review, it appeared that the clinician most probably reviewed only one of them. There ought to be a system in place when ensuring that a scan review can only be completed if all the scans taken are reviewed by a second clinician.
(c) The Falls Assessment Tool was not properly completed or reviewed by staff;
(d) Hospital staff have no training in how to assess and deal with private equipment brought from outside such as an electric wheelchair and the safety features of such devices;
(e) By hospital staff not recording Mr Harichandra’s adverse reaction to the Naso-Gastric tube insertion , future clinicians would have been unaware of this severe reaction when treating him and considering how his important nutritional needs should be met had he survived.
” 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 Royal Free Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to properly explain CT scan interpretation errors
Wider context from the report “I am concerned that:
(a) The error by the original clinician who interpreted the CT scan images of 5th December 2019 has not been properly explained .
(b) The Consultant Radiologist who reviewed the CT scan images of the 5th December 2019 should have noticed the clear and obvious neck fracture. Although there were 2 scans of the 5th December 2019 to review, it appeared that the clinician most probably reviewed only one of them. There ought to be a system in place when ensuring that a scan review can only be completed if all the scans taken are reviewed by a second clinician.
(c) The Falls Assessment Tool was not properly completed or reviewed by staff;
(d) Hospital staff have no training in how to assess and deal with private equipment brought from outside such as an electric wheelchair and the safety features of such devices;
(e) By hospital staff not recording Mr Harichandra’s adverse reaction to the Naso-Gastric tube insertion, future clinicians would have been unaware of this severe reaction when treating him and considering how his important nutritional needs should be met had he survived.
” 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 Royal Free Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of training for hospital staff in assessing and managing externally provided equipment and its safety features
Wider context from the report “I am concerned that:
(a) The error by the original clinician who interpreted the CT scan images of 5th December 2019 has not been properly explained.
(b) The Consultant Radiologist who reviewed the CT scan images of the 5th December 2019 should have noticed the clear and obvious neck fracture. Although there were 2 scans of the 5th December 2019 to review, it appeared that the clinician most probably reviewed only one of them. There ought to be a system in place when ensuring that a scan review can only be completed if all the scans taken are reviewed by a second clinician.
(c) The Falls Assessment Tool was not properly completed or reviewed by staff;
(d) Hospital staff have no training in how to assess and deal with private equipment brought from outside such as an electric wheelchair and the safety features of such devices ;
(e) By hospital staff not recording Mr Harichandra’s adverse reaction to the Naso-Gastric tube insertion, future clinicians would have been unaware of this severe reaction when treating him and considering how his important nutritional needs should be met had he survived.
” 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 Royal Free Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure by Consultant Radiologists to identify clear and obvious neck fractures on CT scans
Wider context from the report “I am concerned that:
(a) The error by the original clinician who interpreted the CT scan images of 5th December 2019 has not been properly explained.
(b) The Consultant Radiologist who reviewed the CT scan images of the 5th December 2019 should have noticed the clear and obvious neck fracture . Although there were 2 scans of the 5th December 2019 to review, it appeared that the clinician most probably reviewed only one of them. There ought to be a system in place when ensuring that a scan review can only be completed if all the scans taken are reviewed by a second clinician.
(c) The Falls Assessment Tool was not properly completed or reviewed by staff;
(d) Hospital staff have no training in how to assess and deal with private equipment brought from outside such as an electric wheelchair and the safety features of such devices;
(e) By hospital staff not recording Mr Harichandra’s adverse reaction to the Naso-Gastric tube insertion, future clinicians would have been unaware of this severe reaction when treating him and considering how his important nutritional needs should be met had he survived.
” Open source report
21 Aug 2020 Malyun Habib KARAMA · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Lack of national-level learning about the increased risk of uterine rupture in multigravida mothers View source Unavailability of a computer in the delivery suite for contemporaneous observation recording View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Malyun Habib KARAMA · 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
Malyun Karama died at the Royal Free Hospital from a uterine rupture after misoprostol was administered in doses exceeding national guidelines to induce labour following an intrauterine death. Abnormal observations were relayed to a senior registrar, but the doctor did not attend immediately. Concerns included the need for national learning about the increased risk of rupture in multigravida mothers and the lack of a computer in the delivery suite for contemporaneous recording of observations.
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 Royal Free Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of national-level learning about the increased risk of uterine rupture in multigravida mothers
Wider context from the report “However, the Royal Free has not yet taken any steps to ensure that there is learning at a national level of the increased risk of rupture in a multi gravida mother . The more widely known increased risk is simply of vaginal birth after caesarean .
” 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 Royal Free Hospital; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a computer in the delivery suite for contemporaneous observation recording
Wider context from the report “Also, one of the midwives looking after Malyun Karama explained that there was no computer in the delivery suite and so she could not record her observations contemporaneously or without leaving the room . This is sub optimal.
” Open source report
5 Jan 2018 Patrick Stephen Moran · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Failure to use insulin-specific syringes when drawing up and administering insulin View source Lack of a process to review continued compliance with CAS alerts View source Lack of mandatory training for doctors on insulin-specific devices View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Patrick Stephen Moran · 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
Patrick Stephen Moran was admitted with severe peripheral vascular disease, left foot gangrene and ongoing leg pain. During angiography and angioplasty, he suffered an iliac artery rupture; his left leg became non-viable and was amputated, while his right leg later deteriorated. The report identified concerns about a tenfold insulin dosing error involving use of a standard syringe, the lack of mandatory diabetes and insulin-device training, and the absence of an organisation-wide process to review compliance with safety alerts.
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 Royal Free Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to use insulin-specific syringes when drawing up and administering insulin
Wider context from the report “(1) During the procedure under local anaesthetic on 25 July 2017 Mr Moran continued to bleed due to the unknown existence of the rupture at that time. He developed hyperkalaemia and was administered an insulin-dextrose infusion. He was to be infused 10 units (0.1ml) on insulin but was mistakenly infused with 100 units (1ml). The serious incident investigation identified that the ST4 Anaesthetist did not use an insulin syringe but instead used a normal 1ml syringe. The use of this syringe was common practice within the anaesthetic department in spite of the issue of alert NPSA/2010/RRR013.
(2) Since 2010 diabetes was removed from the mandatory training requirements across the organisation. As a result there is currently no mandatory training provided to doctors within the Trust to advise them of use of insulin specific devices when drawing up and administering insulin. It is apparent from the action plan that emails have been sent to Consultant Anaesthetists in this regard.
(3) There is currently no process across the organisation to review continued compliance with CAS alerts and ensure that changes made across the Trust still reflect the requirements of previously issued alerts.
” 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 Royal Free Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of a process to review continued compliance with CAS alerts
Wider context from the report “(1) During the procedure under local anaesthetic on 25 July 2017 Mr Moran continued to bleed due to the unknown existence of the rupture at that time. He developed hyperkalaemia and was administered an insulin-dextrose infusion. He was to be infused 10 units (0.1ml) on insulin but was mistakenly infused with 100 units (1ml). The serious incident investigation identified that the ST4 Anaesthetist did not use an insulin syringe but instead used a normal 1ml syringe. The use of this syringe was common practice within the anaesthetic department in spite of the issue of alert NPSA/2010/RRR013.
(2) Since 2010 diabetes was removed from the mandatory training requirements across the organisation. As a result there is currently no mandatory training provided to doctors within the Trust to advise them of use of insulin specific devices when drawing up and administering insulin. It is apparent from the action plan that emails have been sent to Consultant Anaesthetists in this regard.
(3) There is currently no process across the organisation to review continued compliance with CAS alerts and ensure that changes made across the Trust still reflect the requirements of previously issued alerts.
” 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 Royal Free Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory training for doctors on insulin-specific devices
Wider context from the report “(1) During the procedure under local anaesthetic on 25 July 2017 Mr Moran continued to bleed due to the unknown existence of the rupture at that time. He developed hyperkalaemia and was administered an insulin-dextrose infusion. He was to be infused 10 units (0.1ml) on insulin but was mistakenly infused with 100 units (1ml). The serious incident investigation identified that the ST4 Anaesthetist did not use an insulin syringe but instead used a normal 1ml syringe. The use of this syringe was common practice within the anaesthetic department in spite of the issue of alert NPSA/2010/RRR013.
(2) Since 2010 diabetes was removed from the mandatory training requirements across the organisation. As a result there is currently no mandatory training provided to doctors within the Trust to advise them of use of insulin specific devices when drawing up and administering insulin. It is apparent from the action plan that emails have been sent to Consultant Anaesthetists in this regard.
(3) There is currently no process across the organisation to review continued compliance with CAS alerts and ensure that changes made across the Trust still reflect the requirements of previously issued alerts.
” 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