PFD report

Chamali BIBI · Prevention of Future Deaths report

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Issued 9 Oct 2024•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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

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 flag low-volume PAO practitioners
  2. Failure of trusts to recognise PAO as a distinct procedure
  3. Insufficient PAO experience among surgeons performing the procedure
    Part of recurring concern: Unsafe assurance of doctors' procedural competence
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    Further information on relevant clinical and professional standards and guidance should be sought from the RCS of England or BOA.

    Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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

Failure to flag low-volume PAO practitioners

Wider context from the report

“The issue that I bring to your attention is this. At inquest, I heard evidence that PAOs should only be conducted by surgeons expert in this procedure. I heard that only those undertaking this procedure frequently, with mentor feedback on the surgery taking into account the post operative imaging, can gain the necessary experience to become expert. However, the majority of the surgeons on the specialist register are the only practitioners within their trust performing the surgery and the majority undertake fewer than ten per annum each. Further, the register is voluntary. Outliers do not appear to have been flagged. It is not clear to me whether all trusts recognise that the PAO is a different procedure, rather than simply being a different technique. ”

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 of trusts to recognise PAO as a distinct procedure

Wider context from the report

“The issue that I bring to your attention is this. At inquest, I heard evidence that PAOs should only be conducted by surgeons expert in this procedure. I heard that only those undertaking this procedure frequently, with mentor feedback on the surgery taking into account the post operative imaging, can gain the necessary experience to become expert. However, the majority of the surgeons on the specialist register are the only practitioners within their trust performing the surgery and the majority undertake fewer than ten per annum each. Further, the register is voluntary. Outliers do not appear to have been flagged. It is not clear to me whether all trusts recognise that the PAO is a different procedure, rather than simply being a different technique. ”

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

Insufficient PAO experience among surgeons performing the procedure

Wider context from the report

“The issue that I bring to your attention is this. At inquest, I heard evidence that PAOs should only be conducted by surgeons expert in this procedure. I heard that only those undertaking this procedure frequently, with mentor feedback on the surgery taking into account the post operative imaging, can gain the necessary experience to become expert. However, the majority of the surgeons on the specialist register are the only practitioners within their trust performing the surgery and the majority undertake fewer than ten per annum each. Further, the register is voluntary. Outliers do not appear to have been flagged. It is not clear to me whether all trusts recognise that the PAO is a different procedure, rather than simply being a different technique. ”

Is this part of a recurring concern?

Yes — Unsafe assurance of doctors' procedural competence.

Open source report

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

Further information on relevant clinical and professional standards and guidance should be sought from the RCS of England or BOA.

Verbatim wording from the response

“NHS England are not the responsible organisation for the relevant clinical and professional standards and guidance raised in this matter. The Coroner may wish to refer to the Royal College of Surgeons (RCS) of England or the British Orthopaedic Association (BOA) if they feel they require further information.”

Source location

Response from NHS England
Page 1 · response
Published 14 October 2024

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

Relevant clinical and professional standards and guidance are outside NHS England’s responsibility.

Verbatim wording from the response

“NHS England are not the responsible organisation for the relevant clinical and professional standards and guidance raised in this matter. The Coroner may wish to refer to the Royal College of Surgeons (RCS) of England or the British Orthopaedic Association (BOA) if they feel they require further information.”

Source location

Response from NHS England
Page 1 · response
Published 14 October 2024

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

Further comment on the specific concerns is not appropriate based on the information provided and matters addressed by the Trust.

Verbatim wording from the response

“It is not appropriate for NHS England to provide further comment on the concerns raised in your Report, based on the information provided. I understand from your Report that you are satisfied that Barts Health NHS Trust have addressed several matters which you felt required further attention, and undertakings were given to you in court in this respect. Your Report has also been sent to my regional colleagues in London as part of our internal Regulation 28 assurance processes. It is not therefore appropriate for NHS England to provide further comment on these specific concerns.”

Source location

Response from NHS England
Page 1 · response
Published 14 October 2024

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

Trusts and orthopaedic surgeons should already recognise PAO as a specialist procedure requiring suitably trained and experienced clinicians.

Verbatim wording from the response

“Your Report raises the concern that periacetabular osteotomy (PAO) procedures may not be being carried out by suitably experienced practitioners and that Trusts may not recognise it as being a specialist procedure, as opposed to a surgical technique. My response to the Coroner has been informed by specialist orthopaedic clinical opinion.”

Source location

Response from NHS England
Page 1 · response
Published 14 October 2024

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.2

  1. 1

    Share the Report with London regional colleagues through internal Regulation 28 assurance processes.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 14 October 2024.
  2. 2

    Discuss received Prevention of Future Deaths reports through the Regulation 28 Working Group to share learning and identify emerging trends requiring review or action.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 14 October 2024.

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

Share the Report with London regional colleagues through internal Regulation 28 assurance processes.

Verbatim wording from the response

“It is not appropriate for NHS England to provide further comment on the concerns raised in your Report, based on the information provided. I understand from your Report that you are satisfied that Barts Health NHS Trust have addressed several matters which you felt required further attention, and undertakings were given to you in court in this respect. Your Report has also been sent to my regional colleagues in London as part of our internal Regulation 28 assurance processes. It is not therefore appropriate for NHS England to provide further comment on these specific concerns.”

Source location

Response from NHS England
Page 1 · response
Published 14 October 2024

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

Discuss received Prevention of Future Deaths reports through the Regulation 28 Working Group to share learning and identify emerging trends requiring review or action.

Verbatim wording from the response

“I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Chamali are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 2 · response
Published 14 October 2024

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