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First report 14 Sep 2018•Latest report 14 Sep 2018

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 TOXBASE linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Birmingham and Solihull

    AI-generated summary

    Paul David Ryley · 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

    Paul David Ryley died at Birmingham Heartlands Hospital on 14 April 2018 from the effects of a paracetamol overdose and paracetamol-induced liver injury. After initially attending hospital, he re-presented with symptoms but routine blood tests were not undertaken and his symptoms were attributed to alcohol withdrawal. The principal concern was that guidance did not clearly address patients re-presenting after a paracetamol overdose, creating a risk that potentially life-saving treatment would not be given.

    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 TOXBASE; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of clear Toxbase guidance for patients re-presenting after a paracetamol overdose

    Wider context from the report

    “1. The Toxbase Guidelines for Paracetamol overdose (which comprise of a general guidance sheet and then several sheets specific to the period since ingestion) were considered and it was identified that they do not expressly state whether or not they apply only to an initial attendance and do not set out any steps to be followed when a patient re-presents within a short time of an initial attendance for a Paracetamol overdose. 2. Evidence was heard from an ED Registrar, ED Consultant and the Consultant Hepatologist that lead the Trust’s root cause analysis investigation that the guidelines are commonly understood by emergency department practitioners within this Trust and elsewhere to be applicable only to the patient’s initial attendance and are therefore not considered when a patient re-attends even when that re-attendance is within days (in this case within 24 hours) of the initial attendance. Evidence from the experienced ED Consultant was that this is what he had understood from local and national training. 3. The evidence before the court was that it is, or ought to be, known that despite a plasma paracetamol level below the therapeutic threshold patients can go on to suffer liver toxicity following a paracetamol overdose and this is clearly stated within the Toxbase guidance. 4. In this case the clinicians did not refer to the Toxbase guidance when the Deceased represented other than to check that on his initial presentation his plasma paracetamol level had been below the therapeutic level (which it had been). 5. The evidence of a Consultant Hepatologist at the inquest was that he could not foresee any real risk in practice from following the guidance within the applicable Toxbase sheet based on time since ingestion even on a representation and to do so would in some cases result in treatment and avoid death. 6. There is therefore a risk that patients are not being given treatment that would increase their chances of survival because clinicians do not have clear guidance on what to do when a patient re-presents and do not regard the existing guidance as applicable. ”
    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 TOXBASE; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to apply Toxbase guidance when patients re-present after a paracetamol overdose

    Wider context from the report

    “1. The Toxbase Guidelines for Paracetamol overdose (which comprise of a general guidance sheet and then several sheets specific to the period since ingestion) were considered and it was identified that they do not expressly state whether or not they apply only to an initial attendance and do not set out any steps to be followed when a patient re-presents within a short time of an initial attendance for a Paracetamol overdose. 2. Evidence was heard from an ED Registrar, ED Consultant and the Consultant Hepatologist that lead the Trust’s root cause analysis investigation that the guidelines are commonly understood by emergency department practitioners within this Trust and elsewhere to be applicable only to the patient’s initial attendance and are therefore not considered when a patient re-attends even when that re-attendance is within days (in this case within 24 hours) of the initial attendance. Evidence from the experienced ED Consultant was that this is what he had understood from local and national training. 3. The evidence before the court was that it is, or ought to be, known that despite a plasma paracetamol level below the therapeutic threshold patients can go on to suffer liver toxicity following a paracetamol overdose and this is clearly stated within the Toxbase guidance. 4. In this case the clinicians did not refer to the Toxbase guidance when the Deceased represented other than to check that on his initial presentation his plasma paracetamol level had been below the therapeutic level (which it had been). 5. The evidence of a Consultant Hepatologist at the inquest was that he could not foresee any real risk in practice from following the guidance within the applicable Toxbase sheet based on time since ingestion even on a representation and to do so would in some cases result in treatment and avoid death. 6. There is therefore a risk that patients are not being given treatment that would increase their chances of survival because clinicians do not have clear guidance on what to do when a patient re-presents and do not regard the existing guidance as applicable. ”
    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