Vascular Access Society Of Britain & Ireland

Private and voluntary organisations · Registered charity

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First report 28 Jul 2017•Latest report 28 Jul 2017

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 Vascular Access Society Of Britain & Ireland linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Northamptonshire

    AI-generated summary

    Pamela Keech · 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

    Pamela Keech, who had end-stage renal failure and received haemodialysis through a leg graft, experienced repeated bleeds from the graft site before being found unconscious with substantial blood loss on 7 July 2015. She died from a catastrophic haemorrhage from the graft site. Concerns included the lack of national guidance and training on predicting and managing fatal graft or fistula haemorrhage, and whether patients with such bleeds are escalated for renal or surgical review.

    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 Vascular Access Society Of Britain & Ireland; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to include the risk of fatal fistula/graft-site haemorrhage in training requirements

    Wider context from the report

    “(2) I heard evidence that the risk of developing a fatal haemorrhage from a fistula/graft site is not part of the training requirement for A&E doctors/paramedic carers ”
    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 Vascular Access Society Of Britain & Ireland; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of national guidance on predicting and managing graft/fistula haemorrhage

    Wider context from the report

    “(1) I heard evidence that there is no National Guidance on how to predict and manage a fatal graft/fistula haemorrhage ”
    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 Vascular Access Society Of Britain & Ireland; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to escalate fistula/graft-site bleeds for renal or surgical review

    Wider context from the report

    “(3) I am concerned that other patients presenting with bleeds from fistula/graft sites might not be escalated for renal/surgical review before a fatal bleed presents. ”
    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