PFD report

William Arthur Bows · Prevention of Future Deaths report

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Issued 28 Jul 2015•South Yorkshire (Eastern)

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

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

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 raised2

  1. Failure to ensure adequate monitoring during the first twelve months of Amiodarone treatment
    Part of recurring concern: Unsafe amiodarone treatment management
  2. Lack of protocols or guidance for monitoring patients prescribed Amiodarone
    Part of recurring concern: Unsafe amiodarone treatment management
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

    Maintain and revise the shared-care protocol defining amiodarone monitoring responsibilities and required liver, thyroid, respiratory and toxicity testing.

    Stated by Sheffield Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2015.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    An appropriate amiodarone protocol existed, covered monitoring and GP communication, and was followed during the inpatient stay.

    Stated by Sheffield Teaching Hospitals NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 ensure adequate monitoring during the first twelve months of Amiodarone treatment

Wider context from the report

“(2) With regard to the development of Amiodarone toxicity, I heard evidence that should this complication develop it usually does so within the first twelve months or so of commencing this drug and linked with (1) above, there was nothing before me to suggest primary care providers, or indeed secondary care prescribers, were taking steps to ensure there was adequate monitoring during this period. ”

Is this part of a recurring concern?

Yes — Unsafe amiodarone treatment management.

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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 protocols or guidance for monitoring patients prescribed Amiodarone

Wider context from the report

“(1) There was no evidence of any protocols in place or guidance for advising primary care providers of the need to closely monitor patients who have been prescribed Amiodarone, particularly in relation to liver function tests, thyroid tests and respiratory difficulties. ”

Is this part of a recurring concern?

Yes — Unsafe amiodarone treatment management.

Open source report

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

Maintain and revise the shared-care protocol defining amiodarone monitoring responsibilities and required liver, thyroid, respiratory and toxicity testing.

Verbatim wording from the response

“I am pleased to reassure you that there is and was an appropriate policy in place. The Shared Care Protocol for Amiodarone was initially developed in Sheffield in 2007 by the cardiology team in conjunction with the then Sheffield PCT. It has been revised several times since, so that it was the third edition that was current at the time of the prescription (Appendix 1). It was subsequently revised further in 2014, a version developed by Dr Sheridan, Consultant Cardiologist, STHFT and Richard Crosby, Head of Primary Care Clinical Support, NHS West and South Yorkshire and Bassetlaw CSU.”

Source location

2015-0301-Response-by-Sheffield-Teaching-Hospitals-NHS-Trust
Page 1 · response
Published 28 July 2015

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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

An appropriate amiodarone protocol existed, covered monitoring and GP communication, and was followed during the inpatient stay.

Verbatim wording from the response

“I am pleased to reassure you that there is and was an appropriate policy in place. The Shared Care Protocol for Amiodarone was initially developed in Sheffield in 2007 by the cardiology team in conjunction with the then Sheffield PCT. It has been revised several times since, so that it was the third edition that was current at the time of the prescription (Appendix 1). It was subsequently revised further in 2014, a version developed by Dr Sheridan, Consultant Cardiologist, STHFT and Richard Crosby, Head of Primary Care Clinical Support, NHS West and South Yorkshire and Bassetlaw CSU.”

Source location

2015-0301-Response-by-Sheffield-Teaching-Hospitals-NHS-Trust
Page 1 · response
Published 28 July 2015

Open published response

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

    Develop an amiodarone passport and patient handheld information booklet explaining monitoring requirements and potentially life-threatening side effects.

    Stated by Sheffield Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2015.

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

Develop an amiodarone passport and patient handheld information booklet explaining monitoring requirements and potentially life-threatening side effects.

Verbatim wording from the response

“I therefore believe that an appropriate protocol was in place at the time of the prescription of amiodarone and that this was followed during the inpatient stay and communicated to the GP. Since this case, but not because of it, to further improve the safety of patients taking amiodarone, an Amiodarone Passport and Patient Handheld Information Booklet has been developed which provides key information about the drug, including the monitoring regime and the potential life threatening side effects (Appendix 5).”

Source location

2015-0301-Response-by-Sheffield-Teaching-Hospitals-NHS-Trust
Page 2 · response
Published 28 July 2015

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