Sultana Choudhury · Prevention of Future Deaths report

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Issued 7 Sep 2023•East London

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
3

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
3

Described in responses

Recipients and published responses

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 raised3

  1. Failure to withhold low molecular weight heparin VTE prophylaxis in the presence of active bleeding
    Part of recurring concern: Inadequate thromboprophylaxis for patients at risk of venous thromboembolism
  2. Failure to diagnose ongoing renal haemorrhage
  3. Failure to adequately monitor patients during admission

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. Department of Health and Social Care

    Operate the Learn from Patient Safety Events Service to help providers learn from recorded patient safety events.

  2. Department of Health and Social Care

    Continue supporting the NHS with system partners to improve leadership and patient safety.

  3. Department of Health and Social Care

    Implement the Patient Safety Incident Response Framework to change how providers respond to and learn from patient safety incidents.

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 withhold low molecular weight heparin VTE prophylaxis in the presence of active bleeding

Wider context from the report

“2. The clinical decision to administer VTE prophylaxis in the form of low molecular weight heparin on admission to a patient with a patent bleed, evidenced by haematuria. ”

Is this part of a recurring concern?

Yes — Inadequate thromboprophylaxis for patients at risk of venous thromboembolism.

Open source report

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 diagnose ongoing renal haemorrhage

Wider context from the report

“1. The trust’s failure to diagnose an obvious ongoing renal haemorrhage in a patient with; a recent history of renal biopsy, worsening clinical observations in keeping with hypovolaemia and a plummeting haemoglobin count. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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 monitor patients during admission

Wider context from the report

“3. The failure to adequately monitor Mrs Choudhury during her 3-day admission that allowed her to deteriorate into a preventable peri-arrest state. ”

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

Operate the Learn from Patient Safety Events Service to help providers learn from recorded patient safety events.

Verbatim wording from the response

“Over the last decade, we have relentlessly pursued higher patient safety standards across the NHS. Together with system partners, we will keep supporting the NHS to achieve continuous improvement in leadership and safety. This includes implementing key programmes from the first NHS Patient Safety Strategy to help create a positive safety culture and a widespread focus on reducing avoidable patient harm. Several national programmes have been rolled out under the first NHS Patient Safety Strategy, including:”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 14 September 2023

Open published response

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 supporting the NHS with system partners to improve leadership and patient safety.

Verbatim wording from the response

“Over the last decade, we have relentlessly pursued higher patient safety standards across the NHS. Together with system partners, we will keep supporting the NHS to achieve continuous improvement in leadership and safety. This includes implementing key programmes from the first NHS Patient Safety Strategy to help create a positive safety culture and a widespread focus on reducing avoidable patient harm. Several national programmes have been rolled out under the first NHS Patient Safety Strategy, including:”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 14 September 2023

Open published response

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 the Patient Safety Incident Response Framework to change how providers respond to and learn from patient safety incidents.

Verbatim wording from the response

“Over the last decade, we have relentlessly pursued higher patient safety standards across the NHS. Together with system partners, we will keep supporting the NHS to achieve continuous improvement in leadership and safety. This includes implementing key programmes from the first NHS Patient Safety Strategy to help create a positive safety culture and a widespread focus on reducing avoidable patient harm. Several national programmes have been rolled out under the first NHS Patient Safety Strategy, including:”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 14 September 2023

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