Mohammad Ali Asghar · Prevention of Future Deaths report

On 17th September 2024, this court commenced an investigation into the death of Mohammad Ali Asghar aged 82 years. The investigation concluded at the end of the inquest on 14/05/2025. The court returned a narrative conclusion.

“Mohammad Ali Asghar died in hospital on 14th September 2024. Dr Asghar was admitted to hospital with shortness of breath and fluid overload on 8th September 2024. During treatment, Dr Asghar suffered a cardiac arrest caused by, haemorrhagic pericarditis, heart failure and an iatrogenic injury to his bladder caused during necessary catheterisation.”

Mr Asghar’s medical cause of death was determined as;

1a Cardiac arrest
1b Haemorrhagic Pericarditis, Iatrogenic bladder haemorrhage
1c Decompensated heart failure
II Hypertension, Cirrhotic Liver (Cryptogenic), Old Myocardial Infarction

Mr Asghar was admitted to hospital on 8/9/24 with worsening shortness of breath on exertion. Following tests it was identified that Mr Asghar was suffering from decompensated heart failure with hypervolaemic hyponatraemia (low sodium caused by fluid overload), deranged liver function and constipation.

Mr Asghar treatment included intravenous diuresis to offload fluid and he was commenced on a fluid restriction, daily bloods and weights were requested.

A catheter was inserted on 13/9/24 to help monitor fluid input and output monitoring. Following catheterisation there was some haematuria with clots (blood in the urine) and the plan was to replace the catheter.

Following removal of the catheter the patient went to the toilet to pass urine and collapsed. Mr Asghar went into cardiac arrest and CPR was unsuccessful.

1. A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice. In this case the trust’s Datix incident reporting system, morbidity and mortality meeting process and PSIRF procedure were inadequate.

2. Despite concerns being raised by a medical examiner, a coroner’s court finding that an iatrogenic injury was contributory to death, and an express direction from this court for the case to be reviewed, no patient safety framework investigation has occurred.

3. Correspondence received from the Trust sent three months after the inquest that seeks to explain why a PSRF investigation was not undertaken in this case betrays the fact that senior governance staff at the Trust still do not understand NHS England guidance on what should trigger a patient safety investigation.