PFD report

Lauren Louise MURDOCK · Prevention of Future Deaths report

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Issued 4 May 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.

View original report
Concerns
4

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
12

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 raised4

  1. Miscalculation of clot risk when assessing eligibility for the combined contraceptive pill
  2. Failure to calculate cardiovascular risk when assessing eligibility for the combined contraceptive pill
  3. Failure to record significantly elevated blood pressure readings in the medical record
    Part of recurring concern: Unsafe recognition and response to significantly abnormal blood pressure
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.7

  1. Action

    Implement a reception blood-pressure monitoring protocol covering receptionist duties, doctor notification and abnormal readings.

    Stated by Partners, Lathom Road Medical CentreStated completedThe respondent said that this action was complete when they made their response on 26 April 2022.
  2. Action

    Maintain receptionist vigilance and, where possible, supervise patients using the monitor to ensure readings reach the doctor.

    Stated by Partners, Lathom Road Medical CentreStated completedThe respondent said that this action was complete when they made their response on 26 April 2022.
  3. Action

    Maintain staff vigilance to ensure patients using the machine submit their readings before leaving.

    Stated by Lathom Road Medical CentreStated in progressThe respondent said that this action was in progress when they made their response on 26 April 2022.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Receptionist supervision of blood pressure monitoring may not be possible during short staffing or busy periods.

    Stated by Partners, Lathom Road Medical CentreUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Miscalculation of clot risk when assessing eligibility for the combined contraceptive pill

Wider context from the report

“The general practitioner (GP) who prescribed Ms Murdock the combined contraceptive pill consulted the UK medical eligibility criteria (MEC) guidelines before she did so. However, she then miscalculated Ms Murdock’s clot risk and she failed to calculate her cardiovascular risk. She miscalculated the clot risk because she did not appreciate the difference between a family member with history of clot over the age of 45 years, and one under the age of 45 years. If she had calculated correctly, she would have recognised that Ms Murdock was at higher risk and she would have taken a different course of action. She failed to calculate the cardiovascular risk because did not notice the relevant box in the MEC guidelines 11 page summary. If she had noticed the box, she would have recognised that Ms Murdock had multiple cardiovascular risk factors (obesity and smoking) and should only be prescribed Dianette following specialist consultation, if at all. ”

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 calculate cardiovascular risk when assessing eligibility for the combined contraceptive pill

Wider context from the report

“The general practitioner (GP) who prescribed Ms Murdock the combined contraceptive pill consulted the UK medical eligibility criteria (MEC) guidelines before she did so. However, she then miscalculated Ms Murdock’s clot risk and she failed to calculate her cardiovascular risk. She miscalculated the clot risk because she did not appreciate the difference between a family member with history of clot over the age of 45 years, and one under the age of 45 years. If she had calculated correctly, she would have recognised that Ms Murdock was at higher risk and she would have taken a different course of action. She failed to calculate the cardiovascular risk because did not notice the relevant box in the MEC guidelines 11 page summary. If she had noticed the box, she would have recognised that Ms Murdock had multiple cardiovascular risk factors (obesity and smoking) and should only be prescribed Dianette following specialist consultation, if at all. ”

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 record significantly elevated blood pressure readings in the medical record

Wider context from the report

“At inquest, I heard that Lauren visited the practice on 13 October 2021 and saw a healthcare assistant. Her blood pressure was taken and was found to be significantly elevated at 166/90, with a heart rate of 98. That blood pressure reading does not appear to have found its way to Ms Murdock’s medical record, and it was certainly not brought to Dr ████████ attention. ”

Is this part of a recurring concern?

Yes — Unsafe recognition and response to significantly abnormal blood pressure.

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 bring significantly elevated blood pressure readings to the responsible clinician’s attention

Wider context from the report

“At inquest, I heard that Lauren visited the practice on 13 October 2021 and saw a healthcare assistant. Her blood pressure was taken and was found to be significantly elevated at 166/90, with a heart rate of 98. That blood pressure reading does not appear to have found its way to Ms Murdock’s medical record, and it was certainly not brought to Dr ████████ attention. ”

Is this part of a recurring concern?

Yes — Unsafe recognition and response to significantly abnormal blood pressure.

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 reception blood-pressure monitoring protocol covering receptionist duties, doctor notification and abnormal readings.

Verbatim wording from the response

“We have also created a protocol for blood pressure monitoring in the reception area for staff to follow, this clearly highlights the role of the receptionist in the monitoring process, guidelines for informing the doctor, abnormal values.”

Source location

Response from Lathom Road Medical Centre
Page 1 · response
Published 26 April 2022

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

Maintain receptionist vigilance and, where possible, supervise patients using the monitor to ensure readings reach the doctor.

Verbatim wording from the response

“A significant event analysis meeting was also held on 20th April 2022. This included doctors, practice manager and reception staff. We discussed possible options to prevent this scenario recurring and have actioned the most feasible options. Where possible, the receptionist should remain with the patient and supervise the blood pressure monitoring, ensuring the reading is brought to the attention of the doctor. This of course may not be possible when short staffed or during busy periods, however staff to remain vigilant of any patients using the machine so ensure they do not leave before submitting a reading.”

Source location

Response from Lathom Road Medical Centre
Page 1 · response
Published 26 April 2022

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

Maintain staff vigilance to ensure patients using the machine submit their readings before leaving.

Verbatim wording from the response

“Staff to remain vigilant of any patients using the machine to ensure patients do not leave without submitting a reading.”

Source location

Response from Lathom Road Medical Centre_Event Analysis
Page 2 · response
Published 26 April 2022

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

Relocate the blood-pressure machine to the opposite reception-area wall to improve staff oversight while preserving confidentiality.

Verbatim wording from the response

“1. Re-site the machine closer to the reception desk so staff can keep a closer eye on the patients using the machine, the only problem with this is that it can’t be placed right next to the reception desk as it would raise confidentiality issues with the patients already queuing at the front desk. Reception staff suggested to place the machine on the opposite wall of the reception area where they would have better oversight of the patient – we shall try this.”

Source location

Response from Lathom Road Medical Centre_Event Analysis
Page 2 · response
Published 26 April 2022

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

Place a sign above the blood-pressure machine directing patients to give their readings to reception.

Verbatim wording from the response

“A sign has been placed above the blood pressure machine guiding patients to hand the reading to the receptionist once checked.”

Source location

Response from Lathom Road Medical Centre_Event Analysis
Page 2 · response
Published 26 April 2022

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

Update the UK MEC using the feedback to consider formatting that maximizes usability for clinicians.

Verbatim wording from the response

“We have reviewed the circumstances described in your report, and whilst we cannot comment on the clinical aspects with the limits of information provided, we note that the comments regarding use of the UK MEC. The FSRH strives to ensure that the UK MEC and all its clinical products such as guidelines, are both evidence based and accessible. In this instance, our reading of the information provided in your report is that the clinician treating Ms Murdock followed the UK MEC but did not notice information on page 11. We are commencing a planned update to the UK MEC in 2022, ahead of release in 2023, and we will use this feedback to consider how we can best format the content to maximise usability for clinicians.”

Source location

Response from Faculty of Sexual & Reproductive Healthcare
Page 1 · response
Published 26 April 2022

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

Explore whether a risk calculator could form part of a potential guideline-support app during early scoping.

Verbatim wording from the response

“With regard to a suggestion for a ‘risk calculator’, the FSRH is currently in the preliminary stages of considering opportunities to create an APP to better support our highly valued guidelines and standards for professional use. Whilst it is not yet confirmed if and when an APP will be developed, which will be determined subject to viability and perceived benefits, we will as part of the early scoping explore whether a ‘risk calculator’ could be a part of this.”

Source location

Response from Faculty of Sexual & Reproductive Healthcare
Page 1 · response
Published 26 April 2022

Open published response

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

Receptionist supervision of blood pressure monitoring may not be possible during short staffing or busy periods.

Verbatim wording from the response

“A significant event analysis meeting was also held on 20th April 2022. This included doctors, practice manager and reception staff. We discussed possible options to prevent this scenario recurring and have actioned the most feasible options. Where possible, the receptionist should remain with the patient and supervise the blood pressure monitoring, ensuring the reading is brought to the attention of the doctor. This of course may not be possible when short staffed or during busy periods, however staff to remain vigilant of any patients using the machine so ensure they do not leave before submitting a reading.”

Source location

Response from Lathom Road Medical Centre
Page 1 · response
Published 26 April 2022

Open published response

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

Continuous staff supervision of every patient using the blood pressure machine is not always possible because reception staff are already occupied with front-desk duties.

Verbatim wording from the response

“5. Dr ████████ suggested having a dedicated member of staff to supervise each patient checking their blood pressure throughout the process. ████████ mentioned that this is not always going to be possible as staff are already busy at the front desk and wouldn’t always have time to supervise every patient. We agreed that if staff members are free then they should try to stay with the patient though the monitoring process, failing that they should give the patient clear instructions to submit their readings to the front desk.”

Source location

Response from Lathom Road Medical Centre_Event Analysis
Page 2 · response
Published 26 April 2022

Open published response

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

Development of an APP, including a risk calculator, is not confirmed and depends on its viability and perceived benefits.

Verbatim wording from the response

“With regard to a suggestion for a ‘risk calculator’, the FSRH is currently in the preliminary stages of considering opportunities to create an APP to better support our highly valued guidelines and standards for professional use. Whilst it is not yet confirmed if and when an APP will be developed, which will be determined subject to viability and perceived benefits, we will as part of the early scoping explore whether a ‘risk calculator’ could be a part of this.”

Source location

Response from Faculty of Sexual & Reproductive Healthcare
Page 1 · response
Published 26 April 2022

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.5

  1. 1

    Send patients starting combined hormonal contraceptives a reminder to recheck and submit blood pressure readings after one month.

    Stated by Partners, Lathom Road Medical CentreStated plannedThe respondent said that this action was planned when they made their response on 26 April 2022.
  2. 2

    Display signage instructing patients to give blood pressure readings to reception staff.

    Stated by Partners, Lathom Road Medical CentreStated completedThe respondent said that this action was complete when they made their response on 26 April 2022.
  3. 3

    Display the blood-pressure protocol prominently in the reception office.

    Stated by Lathom Road Medical CentreStated plannedThe respondent said that this action was planned when they made their response on 26 April 2022.
  4. 4

    Create guidance requiring a two-minute repeat after a raised reading and escalation of pulse rates below 60 or above 100 bpm.

    Stated by Lathom Road Medical CentreStated completedThe respondent said that this action was complete when they made their response on 26 April 2022.
  5. 5

    Use the incident to inform future guideline development work.

    Stated by Faculty of Sexual and Reproductive HealthcareStated plannedThe respondent said that this action was planned when they made their response on 26 April 2022.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    The blood pressure machine cannot be placed beside reception or in the far corridor because of confidentiality, fire-exit and patient privacy constraints.

    Stated by Lathom Road Medical CentreUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
  2. 2

    Restricting blood pressure-machine access to specified patients was not adopted because it would undermine opportunistic blood pressure screening and cause reception difficulties.

    Stated by Lathom Road Medical CentreNo action considered necessaryThe respondent said that no further action was needed.

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

Send patients starting combined hormonal contraceptives a reminder to recheck and submit blood pressure readings after one month.

Verbatim wording from the response

“We have also concluded to send an Accurx text message to any patient being started on combined hormonal contraceptives to recheck their blood pressure in a month, scheduling a reminder text message after a month prompting the patient to submit a reading. Whilst there is no faculty guidance on this, we believe learning from this incident could prevent future deaths.”

Source location

Response from Lathom Road Medical Centre
Page 1 · response
Published 26 April 2022

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

Display signage instructing patients to give blood pressure readings to reception staff.

Verbatim wording from the response

“We have now created a sign and displayed it above the blood pressure monitor. It states to the patient to give their blood pressure reading to the receptionist.”

Source location

Response from Lathom Road Medical Centre
Page 1 · response
Published 26 April 2022

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

Display the blood-pressure protocol prominently in the reception office.

Verbatim wording from the response

“A protocol has been created with clear guidance for staff – only adjustments to be made to it is for patient to wait 2 minutes before repeating the blood pressure if the 1st reading is raised and for staff to highlight to the doctor if the pulse is <60 or >100bpm. This will be placed in clear sight in the reception office.”

Source location

Response from Lathom Road Medical Centre_Event Analysis
Page 2 · response
Published 26 April 2022

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

Create guidance requiring a two-minute repeat after a raised reading and escalation of pulse rates below 60 or above 100 bpm.

Verbatim wording from the response

“A protocol has been created with clear guidance for staff – only adjustments to be made to it is for patient to wait 2 minutes before repeating the blood pressure if the 1st reading is raised and for staff to highlight to the doctor if the pulse is <60 or >100bpm. This will be placed in clear sight in the reception office.”

Source location

Response from Lathom Road Medical Centre_Event Analysis
Page 2 · response
Published 26 April 2022

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

Use the incident to inform future guideline development work.

Verbatim wording from the response

“Once again, our very sincere condolences to Ms Murdock’s family. We will use this incident to inform our guideline development work in the future.”

Source location

Response from Faculty of Sexual & Reproductive Healthcare
Page 1 · response
Published 26 April 2022

Open published response

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

The blood pressure machine cannot be placed beside reception or in the far corridor because of confidentiality, fire-exit and patient privacy constraints.

Verbatim wording from the response

“1. Re-site the machine closer to the reception desk so staff can keep a closer eye on the patients using the machine, the only problem with this is that it can’t be placed right next to the reception desk as it would raise confidentiality issues with the patients already queuing at the front desk. Reception staff suggested to place the machine on the opposite wall of the reception area where they would have better oversight of the patient – we shall try this.”

Source location

Response from Lathom Road Medical Centre_Event Analysis
Page 2 · response
Published 26 April 2022

Open published response

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

Restricting blood pressure-machine access to specified patients was not adopted because it would undermine opportunistic blood pressure screening and cause reception difficulties.

Verbatim wording from the response

“3. Dr ████████ suggested we could have a list of specific criteria for which patients are allowed to check their blood pressure and not allow access to all patients. Reception staff were concerned they would have to face irate patients who are being turned away. Also as the machine was initially procured to help with opportunistic blood pressure screening, Dr ████████ felt it would not serve that purpose if we only allowed certain patients to use it.”

Source location

Response from Lathom Road Medical Centre_Event Analysis
Page 2 · response
Published 26 April 2022

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