PFD report

Caroline LEE · Prevention of Future Deaths report

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Issued 11 Sep 2013•Coventry

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
2

Raised in this report

Recipients
2

Named on the report

Responses found
0

Of 2 recipients

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

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Concerns raised2

  1. Failure of the laboratory to inform ward staff of abnormal potassium results
    Part of recurring concern: Failure to ensure clinical investigation results are reliably available, interpreted and acted uponPart of recurring concern: Unreliable laboratory notification of safety-critical problems and results
  2. Failure of medical staff to recognise the significance of potassium results
    Part of recurring concern: Failure to ensure clinical investigation results are reliably available, interpreted and acted upon
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

Failure of the laboratory to inform ward staff of abnormal potassium results

Wider context from the report

“(1) failure of the medical staff to recognise the significance of the potassium results (2) failure of the laboratory to inform the Ward staff of the abnormal potassium results ”

Is this part of a recurring concern?

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

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 medical staff to recognise the significance of potassium results

Wider context from the report

“(1) failure of the medical staff to recognise the significance of the potassium results (2) failure of the laboratory to inform the Ward staff of the abnormal potassium results ”

Is this part of a recurring concern?

Yes — Failure to ensure clinical investigation results are reliably available, interpreted and acted upon.

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