PFD report

Dildar Shariff · Prevention of Future Deaths report

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Issued 7 Sep 2016•Manchester North

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
2

Raised in this report

Recipients
3

Named on the report

Responses found
2

Of 3 recipients

Stated actions
1

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 raised2

  1. Failure to incorporate the significance of head injury in patients undergoing haemodialysis or with significant uraemia due to renal failure into relevant NICE guidelines
    Part of recurring concern: Unsafe updating of clinical policies and guidance
  2. Lack of awareness within the medical profession of haemorrhage risk after head injury in patients undergoing haemodialysis or with significant uraemia due to renal failure
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.1

  1. Action

    Log the concerns with the guideline surveillance team for consideration when the head injury guidance is next reviewed.

    Stated by National Institute for Health and Care ExcellenceStated completedThe respondent said that this action was complete when they made their response on 7 September 2016.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    The existing head injury guideline does not need amendment because its bleeding-disorder risk factor and CT assessment recommendations already address the concern.

    Stated by National Institute for Health and Care ExcellenceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 incorporate the significance of head injury in patients undergoing haemodialysis or with significant uraemia due to renal failure into relevant NICE guidelines

Wider context from the report

“Evidence was given that patients who are undergoing haemodialysis or with significant uraemia due to renal failure, such as Mr Shariff, are at increased risk of a haemorrhage and that this is not commonly known within the medical profession or referred to in the relevant NICE guidelines. This lack of awareness could create a risk that other deaths will continue to exist or occur in the future and whilst I am satisfied that the Trust have taken this matter very seriously, in that they have implemented appropriate measures to reduce the risk of this occurring in the future, I am concerned with the National procedures as I am mindful that it may take some time for the significance of a head injury within patients with undergoing haemodialysis or with significant uraemia due to renal failure to be incorporated into the NICE guidelines. ”

Is this part of a recurring concern?

Yes — Unsafe updating of clinical policies and guidance.

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

Lack of awareness within the medical profession of haemorrhage risk after head injury in patients undergoing haemodialysis or with significant uraemia due to renal failure

Wider context from the report

“Evidence was given that patients who are undergoing haemodialysis or with significant uraemia due to renal failure, such as Mr Shariff, are at increased risk of a haemorrhage and that this is not commonly known within the medical profession or referred to in the relevant NICE guidelines. This lack of awareness could create a risk that other deaths will continue to exist or occur in the future and whilst I am satisfied that the Trust have taken this matter very seriously, in that they have implemented appropriate measures to reduce the risk of this occurring in the future, I am concerned with the National procedures as I am mindful that it may take some time for the significance of a head injury within patients with undergoing haemodialysis or with significant uraemia due to renal failure to be incorporated into the NICE guidelines. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Log the concerns with the guideline surveillance team for consideration when the head injury guidance is next reviewed.

Verbatim wording from the response

“While we believe that our guideline does not need to be amended as a result of your report, your concerns have been logged with our guideline surveillance team, for their information when the guidance is next considered for update in 2017.”

Source location

2016-0321-Response-by-N.I.C.E
Page 2 · response
Published 7 September 2016

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 existing head injury guideline does not need amendment because its bleeding-disorder risk factor and CT assessment recommendations already address the concern.

Verbatim wording from the response

“We have noted the circumstances around Mr Shariff’s death and the concerns you have raised, in relation to our existing guideline on the assessment and early management of head injury (accessible from our website: www.nice.org.uk/cg176).”

Source location

2016-0321-Response-by-N.I.C.E
Page 1 · response
Published 7 September 2016

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

Clinicians are widely aware that renal failure, uraemia and haemodialysis increase bleeding risk, contrary to the report’s concern about lack of awareness.

Verbatim wording from the response

“You explain in your report that you consider there to be a lack of awareness within the medical profession that people undergoing haemodialysis, or those with significant uremia due to renal failure, are at increased risk of a haemorrhage. Subsequently, you’ve asked for the significance of a head injury in such people to be incorporated into NICE guidelines.”

Source location

2016-0321-Response-by-N.I.C.E
Page 1 · response
Published 7 September 2016

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