Lauren Murdock

SENT BY EMAIL  

ME Hassell 
Senior Coroner 
Inner North London 
St Pancras Coroner’s Court 
Camley Street 
London N1C 4PP 

3rd June 2022 

Dear Ms Hassell, 

Re: Lauren Louise Murdock 

Thank  you  for  your  email  dated  6th  April  2022,  which  was  sent  to  the  Royal  College  of 
Obstetricians and Gynaecologists (RCOG). The RCOG passed to us the specific information 
and question to the FSRH.  We are greatly saddened to hear of this tragic death and send our 
very sincere condolences to Ms Murdock’s family. 

We have reviewed the circumstances described in your report, and whilst we cannot comment 
on  the  clinical  aspects  with  the  limits  of  information  provided,  we  note  that  the  comments 
regarding use of the UK MEC. The FSRH strives to ensure that the UK MEC and all its clinical 
products  such  as  guidelines,  are  both  evidence based  and  accessible.  In this  instance,  our 
reading  of  the  information  provided  in  your  report  is  that  the  clinician  treating  Ms  Murdock 
followed the UK MEC but did not notice information on page 11. We are commencing a planned 
update to the UK MEC in 2022, ahead of release in 2023, and we will use this feedback to 
consider how we can best format the content to maximise usability for clinicians. 

With  regard  to  a  suggestion  for  a  ‘risk  calculator’,  the  FSRH  is  currently  in  the  preliminary 
stages  of  considering  opportunities  to  create  an  APP  to  better  support  our  highly  valued 
guidelines and standards for professional use. Whilst it is not yet confirmed if and when an 
APP will be developed, which will be determined subject to viability and perceived benefits, we 
will as part of the early scoping explore whether a ‘risk calculator’ could be a part of this.  

Once again, our very sincere condolences to Ms Murdock’s family. We will use this incident to 
inform our guideline development work in the future 

Yours sincerely, 

Vice President, Clinical Quality

For the attention of HM Senior Coroner M E Hassell 

Response to prevention of future deaths report issued on 5th April 22 

10th May 2022 

Following the Inquest outcome the practice had already discussed the issue of the missing blood 
pressure reading in the practice meeting on 5th April 22. In that meeting staff were asked to clarify 
their current protocol on recording blood pressure readings submitted by patients using the 
machine in the reception area. They confirmed that they ask patients to give them the slip with the 
blood pressure reading from the monitor once they have checked it, they also confirmed that they 
record this reading in the records and inform the doctor by screen message. They also confirmed 
that if the blood pressure reading was high they would ask the patient to recheck their blood 
pressure. They would then submit these readings to the doctor. 

The practice manager also individually questioned the healthcare assistant and the reception staff 
that were working in reception on 13th of October 2021 if they had any recollection of this patient 
submitting this high blood pressure reading to them. The photo of the blood pressure reading 
submitted by the patient’s mother had a time stamp of 13.36. The patient attended for an 
appointment (to collect a self smear pack) with the Healthcare assistant at 14.35. (The time 
discrepancy has been found to be due to the clocks going forward and the blood pressure monitor 
needing to be manually updated). Unfortunately due to the length of time lapsed since the incident 
none of the staff members could recall seeing the patient, however they were all able to confirm 
that if they had been presented with a blood pressure reading as high as this they would have asked 
the patient to repeat their blood pressure and as per routine practice informed the doctor of the 
reading. 

As a result we are unable to clarify events of that day and how exactly this blood pressure reading 
was unfortunately missed. 

We have now created a sign and displayed it above the blood pressure monitor. It states to the 
patient to give their blood pressure reading to the receptionist. 

We have also created a protocol for blood pressure monitoring in the reception area for staff to 
follow, this clearly highlights the role of the receptionist in the monitoring process, guidelines for 
informing the doctor, abnormal values. 

The machine is calibrated annually to ensure accurate measurement of blood pressure. 

A significant event analysis meeting was also held on 20th April 2022. This included doctors, practice 
manager and reception staff. We discussed possible options to prevent this scenario recurring and 
have actioned the most feasible options. Wherever possible, the receptionist should remain with the 
patient and supervise the blood pressure monitoring, ensuring the reading is brought to the 
attention of the doctor. This of course may not be possible when short staffed or during busy 
periods, however staff to remain vigilant of any patients using the machine to ensure they do not 
leave before submitting a reading.  

We have also concluded to send an Accurx text message to any patient being started on combined 
hormonal contraceptives to recheck their blood pressure in a month, scheduling a reminder text 
message after a month prompting the patient to submit a reading. Whilst there is no faculty 
guidance on this, we believe learning from this incident could prevent future deaths. 

 Partners, Lathom Road Medical Centre 

Appendices 

1.  Practice protocol for blood pressure monitoring in reception 
2.  Signage in reception 
3.  Significant Event Analysis meeting minutes

Lathom Road Medical Centre 
2a Lathom Road, East Ham, London E6 2DU 

Significant event analysis 
LATHOM ROAD MEDICAL CENTRE 

Event Title 

Missing blood pressure reading 

Date of significant event 

Date of significant event meeting 

Name of reporter 

Position of reporter 

Staff Present at meeting 

13/10/21 

21/4/22 

GP 

What happened? 
(Describe what actually happened in detail. Consider for instance, how it happened, where it happened, who was involved, 
and what the impact or potential impact was on the patient, the team, organisation and/or others) 
A 27yr old patient tragically died on 23/10/21. She had been started on the contraceptive pill 3 
months prior. Post mortem revealed she died of Myocardial Infarction likely due to vasospasm from 
underlying hypertension. The patient was not known to have high blood pressure. The mother of the 
patient found a photo of a blood pressure reading taken at our surgery on the patient’s phone post 
mortem, it was dated 13/10/21 and the reading was 166/90. This reading was not entered in the 
records and not brought to the attention of any clinician.  

Why did it happen? 
(Describe the main and underlying reasons – both positive and negative- contributing to why the event happened. 
Consider for instance the professionalism of the team, the lack of a system or a failing in a system, lack of knowledge or the 
complexity and uncertainty associated with the event) 
According to the records the patient did attend the surgery on 13/10/21 to see the HCA to collect a 
self-test smear pack. She had not been booked for a blood pressure check with the HCA. 

The patient was started on the pill in July and she was asked to recheck her blood pressure in 
reception after a month. She may have come to check it for that reason in October. It is not clear 
why the blood pressure reading was not recorded - staff members present on the day could not 
recall seeing the patient or being given a blood pressure slip of a high reading but as it was 6 months 
ago it is difficult to recall. Staff members confirmed their usual practice is to record blood pressure 
readings into records and inform the doctor.  

Therefore we cannot clarify why this happened - if the patient did not submit the reading to a 
member of staff or if she did submit it and it was overlooked. 

What has been learned and what changes should be made 
(Demonstrate that reflection and learning that has taken place on an individual or team basis and that relevant team 
member have been involved in the analysis of the event. Consider, for instance, a lack of education and training; the need 
to follow systems and procedures, effective communication) Also outline the actions that should be implemented, how the 
event not reoccurring can be monitored) 

We have learnt that more robust protocols need to be in place to prevent this from happening again. 
Reception staff are all already aware to record blood pressure readings in the patient records and 
inform the doctor of the reading on the same day. However, at busy times when there are a few 
patients in the waiting room and the phone is ringing or if a receptionist has been called away then it 

  
 
 
 
 
 
 
 
 
 
 
 
 
 
 Lathom Road Medical Centre 
2a Lathom Road, East Ham, London E6 2DU 
is difficult to keep track of all patients coming to use the machine, we can try to safeguard against 
this by ensuring patients are given clear advice before they sit down to check their blood pressure. 

A protocol has been created with clear guidance for staff –  only adjustments to be made to it is for 
patient to wait 2 minutes before repeating the blood pressure if the 1st reading is raised and for staff 
to highlight to the doctor if the pulse is <60 or >100bpm. This will be placed in clear sight in the 
reception office. 

A sign has been placed above the blood pressure machine guiding patients to hand the reading to 
the receptionist once checked. 

Staff to remain vigilant of any patients using the machine to ensure patients do not leave without 
submitting a reading. 

Further suggestions were made by staff at the meeting: 

1.  Re-site the machine closer to the reception desk so staff can keep a closer eye on the 

patients using the machine, the only problem with this is that it can’t be placed right next to 
the reception desk as it would raise confidentiality issues with the patients already queuing 
at the front desk. Reception staff suggested to place the machine on the opposite wall of the 
reception area where they would have better oversight of the patient – we shall try this. 

2.  Dr 

suggested we could place the machine in the far corridor away from the reception 
desk, however again there would be confidentiality issues as that corridor space is between 
2 consulting rooms and patients could potentially be sitting by the bp machine for up to 
15min therefore overhearing consults going on in the adjacent rooms. Except for this area 
there isn’t any other space on the ground floor for the machine to be placed whilst 
maintaining confidentiality and keeping fire exits clear at the same time.  

3.  Dr 

 suggested we could have a list of specific criteria for which patients are allowed to 

check their blood pressure and not allow access to all patients. Reception staff were 
concerned they would have to face irate patients who are being turned away. Also as the 
machine was initially procured to help with opportunistic blood pressure screening, Dr 

4. 

 felt it would not serve that purpose if we only allowed certain patients to use it. 
 suggested contacting the bp machine company to see if they operate any coin slot 
system whereby the patient needs to be given a coin to enter in the machine to be able to 
use it, thereby keeping a closer track on who is using it and returning readings – she will 
contact the company. 

5.  Dr 

 suggested having a dedicated member of staff to supervise each patient checking 

their blood pressure throughout the process. 
to be possible as staff are already busy at the front desk and wouldn’t always have time to 
supervise every patient. We agreed that if staff members are free then they should try to 
stay with the patient though the monitoring process, failing that they should give the patient 
clear instructions to submit their readings to the front desk. 

mentioned that this is not always going