PFD report

Evie Gladys Muir · Prevention of Future Deaths report

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Issued 26 Nov 2025•Essex

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
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 raised2

  1. Failure to widely share hospital reviews of unusual cardiac deaths with clinicians and relevant specialist disciplines
  2. Failure to adequately assess cardiac patients with HLA B27 positivity or rheumatological conditions for associated risks including vasculitis
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.5

  1. Action

    Implement a quality improvement programme and new process for sharing learning from deaths across clinical teams and hospital sites.

    Stated by Mid and South Essex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 2 December 2025.
  2. Action

    Continue increasing awareness of comparable cases among allied rheumatology healthcare professionals.

    Stated by Mid and South Essex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 2 December 2025.
  3. Action

    Invite Cardiology colleagues to Rheumatology departmental meetings to improve education on coronary vasculitis and myopericarditis.

    Stated by Mid and South Essex NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 2 December 2025.

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 widely share hospital reviews of unusual cardiac deaths with clinicians and relevant specialist disciplines

Wider context from the report

“(1) That hospital reviews into unusual cardiac deaths such as this one are not more widely shared with other clinicians involved with a patient’s care, and other disciplines, such as, in this case, rheumatology specialists. This means that the full clinical picture of how a patient died may not be sufficiently widely understood. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Failure to adequately assess cardiac patients with HLA B27 positivity or rheumatological conditions for associated risks including vasculitis

Wider context from the report

“(2) patients with cardiac problems known to be HLA B27 positive or otherwise known to present rheumatological conditions being adequately assessed for the risks which those rheumatological problems might present, include vasculitis. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Implement a quality improvement programme and new process for sharing learning from deaths across clinical teams and hospital sites.

Verbatim wording from the response

“We are currently undertaking a quality improvement programme to improve our processes for learning from deaths in line with our new operating model and clinical governance structure. The new process will allow sharing of learning between teams and across hospital sites.”

Source location

Response from Mid and South Essex NHS Foundation Trust
Page 1 · response
Published 2 December 2025

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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

Continue increasing awareness of comparable cases among allied rheumatology healthcare professionals.

Verbatim wording from the response

“We have therefore agreed a wider learning exercise to raise awareness of cases such as this is required. Our Rheumatology team have confirmed that they will present Miss Muir’s case at the Essex Rheumatology meeting, which is a regional meeting. They will also continue to increase awareness among allied rheumatology health care professionals.”

Source location

Response from Mid and South Essex NHS Foundation Trust
Page 2 · response
Published 2 December 2025

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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

Invite Cardiology colleagues to Rheumatology departmental meetings to improve education on coronary vasculitis and myopericarditis.

Verbatim wording from the response

“The Rheumatology team have confirmed that they will in future invite Cardiology colleagues to their departmental meetings to improve education of coronary vasculitis and myopericarditis. I understand that the Rheumatology team are working hard to improve awareness and management of cases such as Miss Muir’s.”

Source location

Response from Mid and South Essex NHS Foundation Trust
Page 2 · response
Published 2 December 2025

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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

Complete a review of the Learning From Deaths process, including assessing M&M meeting effectiveness and identifying opportunities for cross-specialty learning.

Verbatim wording from the response

“We plan to complete a full review of our Learning From Death’s process this year with the aim of ensuring that it is robust and effective. As part of this work, we will be looking at the effectiveness of M&M meetings and identifying opportunities to elevate their use, with a focus on opportunities for cross-speciality learning.”

Source location

Response from Mid and South Essex NHS Foundation Trust
Page 2 · response
Published 2 December 2025

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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

Present Miss Muir’s case at the regional Essex Rheumatology meeting.

Verbatim wording from the response

“We have therefore agreed a wider learning exercise to raise awareness of cases such as this is required. Our Rheumatology team have confirmed that they will present Miss Muir’s case at the Essex Rheumatology meeting, which is a regional meeting. They will also continue to increase awareness among allied rheumatology health care professionals.”

Source location

Response from Mid and South Essex NHS Foundation Trust
Page 2 · response
Published 2 December 2025

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