PFD report

Umul Kelsum Anna AUDU · Prevention of Future Deaths report

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Issued 27 Jan 2014•Inner North London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
1

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Concerns raised1

  1. Lack of transport heater availability for patient transfers
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. Action

    Keep the transport-heater policy under review for patient-transfer safety.

    Stated by University College London Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 January 2014.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Transport heaters cannot be introduced for all investigations because warming devices containing metallic elements are contraindicated in MRI environments.

    Stated by University College London Hospitals NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of transport heater availability for patient transfers

Wider context from the report

“(1) The lack of transport heater availability was not explained in the written evidence presented by the Trust. I did not judge it appropriate to adjourn the inquest in order to obtain further written or live evidence on this point, as sufficient information was available in order to conclude matters on 24 January 2014. However, it remains a concern that, in similar circumstances, the lack of transport heater could result in future patients becoming hypothermic on transfer, which might result in their death. As such, I am making this report in order that the Trust can respond to this concern. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Keep the transport-heater policy under review for patient-transfer safety.

Verbatim wording from the response

“We will however be keeping the position under review. It is a complex issue and at present we do not believe simply introducing transport heaters is appropriate and, for the reason stated, based on our investigations we do not believe that a lack of transport heater availability in itself could give rise to a risk of future deaths.”

Source location

2014-0038-Response-by-University-College-London-Hospitals-NHS-Foundation-Trust
Page 2 · response
Published 27 January 2014

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Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Transport heaters cannot be introduced for all investigations because warming devices containing metallic elements are contraindicated in MRI environments.

Verbatim wording from the response

“More specifically, MRI scanning (the investigation that the patient in question underwent) is even more problematic. Transport heater devices such as warming blankets contain metallic elements, which are absolutely contraindicated for use in the MRI environment, and indeed there are reports in the literature of patients being burnt in MRI scanners when such devices have been used.”

Source location

2014-0038-Response-by-University-College-London-Hospitals-NHS-Foundation-Trust
Page 1 · response
Published 27 January 2014

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The lack of transport heater availability is not considered, in itself, to create a risk of future deaths.

Verbatim wording from the response

“We will however be keeping the position under review. It is a complex issue and at present we do not believe simply introducing transport heaters is appropriate and, for the reason stated, based on our investigations we do not believe that a lack of transport heater availability in itself could give rise to a risk of future deaths.”

Source location

2014-0038-Response-by-University-College-London-Hospitals-NHS-Foundation-Trust
Page 2 · response
Published 27 January 2014

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Standard measures during patient transfer are considered sufficient to prevent significant hypothermia-related harm, so transport heaters will not be introduced.

Verbatim wording from the response

“Our considered position based on these enquiries and the views of my colleagues is that at present we would not propose to change our policy and introduce transport heaters for the reason set out above. That is:”

Source location

2014-0038-Response-by-University-College-London-Hospitals-NHS-Foundation-Trust
Page 2 · response
Published 27 January 2014

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026