PFD report

Neil HICKMAN · Prevention of Future Deaths report

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Issued 28 Feb 2022•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
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
1

Described in 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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Report evidence summary

Concerns raised1

  1. Failure to measure ferritin levels in patients receiving frequent platelet transfusions
    Part of recurring concern: Failure to reliably monitor ferritin in patients at risk of iron overload
Responses linked to these concerns

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

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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

Failure to measure ferritin levels in patients receiving frequent platelet transfusions

Wider context from the report

“Mr Hickman was given frequent platelet transfusions at K&C, but his ferritin levels were not measured. When he was referred to UCLH, his ferritin level was found to be hugely raised. He was then treated with chelation therapy and ultimately his ferritin returned to a safe level, so this did not impact upon the outcome. However, it might for another patient. I think the reason that K&C does not measure the ferritin levels in such a situation is because K&C does not have funding for chelation therapy to treat iron overload. However, if iron overload is detected, then a referral centre such as UCLH can be called for advice, and the patient and their family can be informed so that they have the option of seeking private treatment. ”

Is this part of a recurring concern?

Yes — Failure to reliably monitor ferritin in patients at risk of iron overload.

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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.1

  1. 1

    Measure ferritin levels for all frequently transfused Myelodysplastic Syndrome patients referred for bone marrow transplantation.

    Stated by East Kent HospitalsStated completedThe respondent said that this action was complete when they made their response on 3 March 2022.

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

Measure ferritin levels for all frequently transfused Myelodysplastic Syndrome patients referred for bone marrow transplantation.

Verbatim wording from the response

“Your PFD Report was discussed in the Haematology Departmental business meeting on 10 March 2022. It has now been agreed that all Myelodysplastic Syndrome patients that are undergoing frequent red cell transfusions and being referred for a bone marrow transplant will have their ferritin levels measured. This will ensure that if iron overload is detected, appropriate measures can be initiated including referral to a specialist centre for urgent treatment. This action has been implemented with immediate effect.”

Source location

2022-0064-Response-from-Kent-and-Canterbury-Hospital_Published
Page 1 · response
Published 3 March 2022

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

Official responses located
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Data last updated 7 September 2026