PFD report

Norma Edwina Holden · Prevention of Future Deaths report

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Issued 25 Apr 2016•Manchester City

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
4

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

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. Incomplete history taking
    Part of recurring concern: Incomplete clinical history-taking
  2. Failure to recognise and act on symptoms of possible anaphylactic shock
    Part of recurring concern: Failure to recognise and respond to anaphylaxisPart of recurring concern: Failure to reliably recognise and respond to acute clinical deterioration
  3. Failure to obtain basic blood tests for infection or sepsis analysis
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

Incomplete history taking

Wider context from the report

“During the inquest evidence was heard to the fact that Mrs Holden presented to the Accident and Emergency Department with a history of abdominal pain. Triage history stated swelling to face and mouth. It appears that Mrs Holden had a swollen tongue and her speech was muffled. ████████ was unaware of the symptoms of swollen tongue and facial swelling. I am concerned that the history taking is incomplete and not reported to treating doctors appropriately and that obvious symptoms appear to have not been noticed and actioned, such as possible anaphylactic shock, and appropriate tests conducted. In addition, basic blood tests were not obtained for analysis of any infection/sepsis, to enable appropriate targeting of antibiotics. ”

Is this part of a recurring concern?

Yes — Incomplete clinical history-taking.

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 recognise and act on symptoms of possible anaphylactic shock

Wider context from the report

“During the inquest evidence was heard to the fact that Mrs Holden presented to the Accident and Emergency Department with a history of abdominal pain. Triage history stated swelling to face and mouth. It appears that Mrs Holden had a swollen tongue and her speech was muffled. ████████ was unaware of the symptoms of swollen tongue and facial swelling. I am concerned that the history taking is incomplete and not reported to treating doctors appropriately and that obvious symptoms appear to have not been noticed and actioned, such as possible anaphylactic shock, and appropriate tests conducted. In addition, basic blood tests were not obtained for analysis of any infection/sepsis, to enable appropriate targeting of antibiotics. ”

Is this part of a recurring concern?

Yes — Failure to recognise and respond to anaphylaxis; Failure to reliably recognise and respond to acute clinical deterioration.

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 obtain basic blood tests for infection or sepsis analysis

Wider context from the report

“During the inquest evidence was heard to the fact that Mrs Holden presented to the Accident and Emergency Department with a history of abdominal pain. Triage history stated swelling to face and mouth. It appears that Mrs Holden had a swollen tongue and her speech was muffled. ████████ was unaware of the symptoms of swollen tongue and facial swelling. I am concerned that the history taking is incomplete and not reported to treating doctors appropriately and that obvious symptoms appear to have not been noticed and actioned, such as possible anaphylactic shock, and appropriate tests conducted. In addition, basic blood tests were not obtained for analysis of any infection/sepsis, to enable appropriate targeting of antibiotics. ”

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 communicate clinical history appropriately to treating doctors

Wider context from the report

“During the inquest evidence was heard to the fact that Mrs Holden presented to the Accident and Emergency Department with a history of abdominal pain. Triage history stated swelling to face and mouth. It appears that Mrs Holden had a swollen tongue and her speech was muffled. ████████ was unaware of the symptoms of swollen tongue and facial swelling. I am concerned that the history taking is incomplete and not reported to treating doctors appropriately and that obvious symptoms appear to have not been noticed and actioned, such as possible anaphylactic shock, and appropriate tests conducted. In addition, basic blood tests were not obtained for analysis of any infection/sepsis, to enable appropriate targeting of antibiotics. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report
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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