PFD report

Noel Williams · Prevention of Future Deaths report

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Issued 13 Mar 2014•Teesside

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
1

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

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Concerns and recipient responses

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Concerns raised1

  1. Failure to communicate recent haemoglobin test results to clinicians assessing fitness for surgery
    Part of recurring concern: Failure to ensure clinical investigation results are reliably available, interpreted and acted uponPart of recurring concern: Unreliable communication of patient-care information between clinical staffPart of recurring concern: Unreliable laboratory notification of safety-critical problems and results
Responses linked to these concerns

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No linked response statements

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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 recent haemoglobin test results to clinicians assessing fitness for surgery

Wider context from the report

“During the course of the evidence given in this inquest evidence was received that there had been a failure of communication in communicating the results of haemoglobin level tests. It was further revealed by the evidence that the haemoglobin level was an important factor in considering a patient's fitness for surgery. The evidence further revealed that had the information concerning the most recent haemoglobin tests carried out on the deceased passed the surgery may have been delayed or alternative treatment plans put in place. Whilst the evidence did also indicate that there were risks in delaying surgery there nonetheless had been an admitted failure to communicate the results of recent haemoglobin tests to the anaesthetist and surgeon performing the index surgery. Clearly if the results of a haemoglobin test are an essential part of the assessment of fitness for surgery then the ability to communicate the most recent tests indicates a potential failure which could cause or contribute to future deaths. ”

Is this part of a recurring concern?

Yes — Failure to ensure clinical investigation results are reliably available, interpreted and acted upon; Unreliable communication of patient-care information between clinical staff; Unreliable laboratory notification of safety-critical problems and results.

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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