PFD report

Sophia Ayuk · Prevention of Future Deaths report

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Issued 20 Jan 2023•East 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: 2
Recipients: 2
Responses found: 1
Stated actions: 20

Recipients and published responses

Department of Health and Social CareNo response found East London NHS Foundation TrustResponse found

Source document

Full report text

This is the full text from the original published report.

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Investigation and inquest

On 19th March 2022 I commenced an investigation into the death of Sophia Ayuk age 34 years. The investigation concluded at the end of an Article Two compliant inquest held on 18th and 19th January 2023. I arrived at a narrative conclusion.

“Sophia Abunaw Ayuk died in hospital on 18th March 2023 as the result of a pulmonary embolism. A deep vein thrombosis had developed in her left calf due to Sophia sitting motionless in her room on the day of her death.
Sophia's behaviour on 18th March 2022 was due to her mental illness.
Ms Ayuk had not taken any food or drink for at least two days prior to her death.

Dehydration may have contributed to the development of Ms Ayuk's thrombosis.”

The medical cause of death was determined following a post-mortem examination;

1a Pulmonary embolus
1b Deep vein thrombosis

II Schizophrenia (treated)

Concerns and recipient responses

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

Concerns raised2

Failure to assess inpatient patients for venous thromboembolism risk
Part of recurring concern: Inadequate thromboprophylaxis for patients at risk of venous thromboembolism
Failure to adequately monitor and record patients’ food and fluid intake
Part of recurring concern: Inadequate management of patients' nutrition and hydration needs

Responses linked to these concerns

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

Actions described in response 13

Action
Disseminate a VTE screening and assessment clinical alert across the Trust.
Stated by East London NHS Foundation TrustStated completed
Action
Add VTE assessment information to new-doctor induction and the junior doctors’ handbook.
Stated by East London NHS Foundation TrustStated completed
Action
Review the Trust’s VTE policy.
Stated by East London NHS Foundation TrustStated planned

Action
Trial Power BI and use it to monitor compliance with VTE risk assessments.
Stated by East London NHS Foundation TrustStated in progress
Action
Employ an Advanced Clinical Practitioner as Consultant Nurse in Physical Health to review in-patient physical health and address concerns in daily safety huddles.
Stated by East London NHS Foundation TrustStated completed
Action
Add antipsychotic medication as a consideration in the VTE assessment tool.
Stated by East London NHS Foundation TrustStated completed
Action
Conduct weekly matron night checks including review of food and fluid charts.
Stated by East London NHS Foundation TrustStated completed
Action
Add RiO pop-up reminders prompting VTE risk assessment when patients’ presentations change.
Stated by East London NHS Foundation TrustStated completed
Action
Include food and fluid charts in the monthly physical health training programme.
Stated by East London NHS Foundation TrustStated completed
Action
Use a new decision-making template for commencing or terminating food and fluid chart monitoring.
Stated by East London NHS Foundation TrustStated completed
Action
Include VTE risk in the monthly physical health training programme.
Stated by East London NHS Foundation TrustStated completed
Action
Conduct daily senior-nurse checks of food and fluid charts for completion.
Stated by East London NHS Foundation TrustStated completed
Action
Implement a nutrition policy emphasizing food and fluid monitoring for in-patients.
Stated by East London NHS Foundation TrustStated completed

Other statements in published responses

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

Recipient-stated actions 7

1
Employ a Band 7 Specialist Dietitian to provide Trust-wide nutritional guidance.
Stated by East London NHS Foundation TrustStated completed
2
Launch a nutrition and dietetics intranet page with advice and resources for in-patient ward teams.
Stated by East London NHS Foundation TrustStated completed
3
Add the St Andrews Nutrition Screening Instrument to RiO.
Stated by East London NHS Foundation TrustStated planned
4
Raise a yellow-card warning with the MHRA concerning Zaponex and pulmonary embolism deaths.
Stated by East London NHS Foundation TrustStated completed
5
Launch a nutrition screening learning module on the Learning Academy.
Stated by East London NHS Foundation TrustStated completed
6
Recruit an approved Band 5 Trust-wide nutrition Dietitian post internationally.
Stated by East London NHS Foundation TrustStated in progress
7
Introduce a dietitian referral system for advice on complex cases.
Stated by East London NHS Foundation TrustStated completed

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

Published report and response evidence

Recipients and published responses

Report evidence summary

Concerns raised2

Failure to assess inpatient patients for venous thromboembolism risk

Failure to adequately monitor and record patients’ food and fluid intake

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.13

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.7

Actions described in response 13

Recipient-stated actions 7