PFD report

Sufia Begum · Prevention of Future Deaths report

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Issued 19 Sep 2018•Birmingham and Solihull

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
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
5

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

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Lack of doctors’ awareness of the BNF mobile device app for identifying potential drug interactions
    Part of recurring concern: Incomplete medication safety guidance for prescribers
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

    Publish and circulate a Medicines Newsletter alert promoting use of the BNF App to check drug interactions when clinical-system checking is unavailable.

    Stated by NHS Birmingham and Solihull Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 19 September 2018.

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 doctors’ awareness of the BNF mobile device app for identifying potential drug interactions

Wider context from the report

“1. I heard evidence at the inquest that the most useful tool to identify potential drug interactions was the BNF mobile device APP. The author of the RCA confirmed that not all doctors were aware of the APP. An alert to all NHS Trusts and GPs would provide this valuable information which may prevent a future death from an unknown drug interaction. ”

Is this part of a recurring concern?

Yes — Incomplete medication safety guidance for prescribers.

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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

Publish and circulate a Medicines Newsletter alert promoting use of the BNF App to check drug interactions when clinical-system checking is unavailable.

Verbatim wording from the response

“On 14th November the CCG included the following alert in its monthly Medicines Newsletter:”

Source location

Sufia-Begum-Response
Page 2 · response
Published 19 September 2018

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Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. 1

    Distribute learning from the case across West Midlands CCGs and providers through the Mortality group.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 September 2018.
  2. 2

    Distribute anonymised case details to all West Midlands GPs through the regular appraisal newsletter.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 19 September 2018.
  3. 3

    Work with Sandwell and West Birmingham Hospitals NHS Trust to obtain assurance that preventive actions are completed.

    Stated by NHS Birmingham and Solihull Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 19 September 2018.
  4. 4

    Notify contracted NHS providers, including walk-in and urgent care centres, to avoid drug interactions and provide assurance this has been addressed.

    Stated by NHS Birmingham and Solihull Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 19 September 2018.

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

Distribute learning from the case across West Midlands CCGs and providers through the Mortality group.

Verbatim wording from the response

“3. NHS England has already distributed learning across all CCGs and Providers in the West Midlands via shared learning at the West Midlands Mortality group meeting held on 16th October 2018.”

Source location

Sufia-Begum-Response2
Page 2 · response
Published 19 September 2018

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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

Distribute anonymised case details to all West Midlands GPs through the regular appraisal newsletter.

Verbatim wording from the response

“2. NHS England will ensure the details of this case are anonymised and distributed across all GPs in the West Midlands via its regular appraisal newsletter.”

Source location

Sufia-Begum-Response2
Page 2 · response
Published 19 September 2018

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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

Work with Sandwell and West Birmingham Hospitals NHS Trust to obtain assurance that preventive actions are completed.

Verbatim wording from the response

“The CCG had been alerted to Mrs Begum’s death through its serious incident reporting process, which requires care providers to report serious incidents in accordance with NHS England Serious Incident Reporting Framework (2015). In response to that report the CCG has contacted Sandwell and West Birmingham Hospitals Trust to seek assurance that actions have taken to prevent a recurrence of this situation, and we continue to work with the Trust to ensure that these actions are completed.”

Source location

Sufia-Begum-Response
Page 1 · response
Published 19 September 2018

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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

Notify contracted NHS providers, including walk-in and urgent care centres, to avoid drug interactions and provide assurance this has been addressed.

Verbatim wording from the response

“The CCG wrote, at the end of October, to all of its contracted NHS providers to notify them of the need to avoid drug interactions and to seek assurance that this has been addressed. This was followed on 2nd November by a letter to primary care providers of walk in centres and urgent care treatment centres notifying the same.”

Source location

Sufia-Begum-Response
Page 1 · response
Published 19 September 2018

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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