PFD report

Sultana Choudhury · Prevention of Future Deaths report

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Issued 7 Sep 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.

View original report
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

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 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
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 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

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.3

  1. 1

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

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 14 September 2023.
  2. 2

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

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 14 September 2023.
  3. 3

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

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 14 September 2023.

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