Amelia Ridout

Tel: 020 7713 0990 
email: info@b-s-h.org.uk 

3 April 2025 

Ms Elizabeth Gray 
Area Coroner for Cambridgeshire & Peterborough 

By email 

Dear Ms Gray, 

Re: Regulation 28 Prevention of Future Deaths Report in respect of  
Amelia Alexandra Anuszka Ridout 

Thank you for providing us the opportunity to respond to your Regulation 28 report, dated 11 
February 2025, regarding the tragic death of Amelia Ridout from a bone marrow biopsy. 

Firstly, we would like to convey our sincere condolences to Amelia’s family. Amelia suffered 
a truly tragic outcome from a routine procedure required for diagnosis and monitoring of 
haematological disease. 

There has been much discussion about actions we can take to minimise the risk of the 
procedure and ensure such a tragedy does not happen again. These actions include: 

1.  Gather data, via survey to trainee haematologists, to understand the training, 

competencies and support they receive in undertaking this procedure, both for adults 
and children.  

2.  Gather data, via a Blood Cancer UK survey, on experiences of adult patients and 

parents of children who have received the procedure. 

3.  Review the literature and evidence regarding adverse outcomes after bone marrow 

aspirate and trephine biopsy on adults and children, and safest techniques.   

4.  With these sources of information, develop a national guideline for recommended 

methodology and include recommendations for training and competency assessment.  

5. 

Improve existing consent processes to include the rare risk of death and add these to 
the guideline.   

6.  Explore the possibility of developing a registry of complications to inform future 

guidelines.  

7.  Establish an audit process for Trusts to monitor their performance and ensure proper 

implementation of national guidance.  

Registered in England and Wales as a Company Limited by Guarantee, No 02645706 and as a charity, No 1005735 
Registered Office: 100 White Lion Street London N1 9PF 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Continued 

8.  Name the recommended method Millie’s method, in accordance with Mr Ridout’s 

request. 

Whilst we acknowledge that completion of these actions will take time, we are pleased to 
confirm that the wheels are already in motion.  

Additionally, we have been in communication with NICE, who has offered to contribute as 
needed, in the guideline production and implementation. 

Yours sincerely, 

President  
British Society for Haematology 

Consultant Haematologist 
Oxford University Hospitals NHS FT 

The British Society for Haematology

Ms Elizabeth Gray  
HM Area Coroner  
Cambridgeshire and  
Peterborough Coroner’s Service 
Lawrence Court  
Princes Street 
Huntingdon  
PE29 3PA 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

2 May 2025  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Ameila Alexandra 
Anuszka Ridout who died on 16 June 2022  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  11 
February 2025 concerning the death of Amelia Alexandra Anuszka Ridout on 16 June 
2022. In advance of responding to the specific concerns raised in your Report, I would 
like to express my deep condolences to  Amelia’s parents and family. NHS England 
are keen to assure the family and the Coroner that the concerns raised about Amelia’s 
care have been listened to and reflected upon.   

I am grateful for the further time granted to respond to your Report, and I apologise for 
any anguish this delay may have caused to Amelia’s parents and family. I realise that 
responses to Coroners’ Reports can form part of the important process of family and 
friends coming to terms with what has happened to their loved ones, and I appreciate 
this will have been an incredibly difficult time for them.  

Your  Report  raises  that  there  should  be  development  and  publication  of  national 
guidelines  and  a  standard  operating  procedure  (SOP)  for  the  carrying  out  of  Bone 
Marrow  Aspirate  (BMA)  and  trephine  biopsy,  and  consideration  of  developing  a 
database to record these procedures and outcomes.  

It  would  not  sit  within  the  remit  of  NHS  England  to  produce  the  relevant  clinical 
guidelines or SOP for BMA and trephine biopsy, although we have engaged with the 
National Institute for Health and Care Excellence (NICE) and the  British Society for 
Haematology (BSH) on the concerns raised in HM Coroner’s Report and have been 
sighted on the responses from NICE and the BSH to the Coroner.  

BMA and  trephine biopsy are  common diagnostic procedures,  used  for  a variety  of 
reasons. Our National Specialty Advisor for Blood and Marrow Transplantation (BMT) 
has considered your Report and confirmed that  the procedures do not sit within the 
NHS England commissioned BMT pathway or within specialised children’s services. It 
is therefore a service directly commissioned by Integrated Care Boards (ICBs), who 
would be expected to ensure that Hospital Trusts have the appropriate processes in 
place to deliver the procedure safely and effectively. The Coroner may wish to engage 
with the relevant ICB in this matter, although my regional Clinical Quality colleagues 

                                                                                                                       
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 for the East of England have been made aware of your Report and the circumstances 
that led to Amelia’s death, and they can liaise with the local ICB directly.   

Bleeding due to vascular injuries is recognised as a known, although adverse, risk of 
bone  marrow  biopsy  and  NHS  England  are  aware  of  individual  Trust  Patient 
Information  Leaflets  (PILs)  that  outline  the  risks  and  details  of  the  procedure,  for 
example: Bone marrow biopsy | The Rotherham NHS Foundation Trust and pl-964.1-
bone-marrow-biopsy.pdf.  

NHS England have however communicated to the BSH that it would be supportive of 
them  developing  the  relevant  national  guidance  for  clinicians.  Our  national  Patient 
Safety Team have advised that they would consider issuing a National Patient Safety 
Alert (NatPSA) to support and raise awareness of key recommendations, although this 
would have to be weighed against the existing NatPSA criteria. We are aware that the 
BSH has already published a demonstration video on ‘How to perform bone marrow 
aspiration and trephine biopsy’.  

Regarding  the  development  of  a  database  to  record  BMA  and  trephine  biopsy 
procedures  and  their  outcomes,  my  colleagues  with  responsibility  for  national 
databases  and  registries  have  considered  this,  together  with  your  Report.  NHS 
England  do  not  consider  there  is  a  need  for  us  to  develop  a  registry  at  this  point, 
however we will undertake to:  

1.  Investigate  further  to  understand  the  evidence  in  this  area,  to  determine  the 
potential root cause, for example, are there any training and / or supervision 
issues associated with this practice. 

2.  Review relevant national guidance and understand how this translates into local 

policies.    

On review of the above and depending on the evidence, NHS England will take any 
necessary and proportionate steps to minimise potential future harm. 

We also note many of the actions being undertaken by the BSH, as the responsible 
professional  society  for  the  procedure,  and  outlined  in  their  response  to  you  which 
include improving existing consent processes, their exploration of the possibility of a 
registry of complications and establishing an audit process for Trusts.  

I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking place around the Reports to Prevent Future Deaths. All reports received are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures  that  key  learnings  and  insights  around  events,  such  as  the  sad  death  of 
Amelia, are shared across the NHS at both a national and regional level and helps us 
to  pay  close  attention  to  any  emerging  trends  that  may  require  further  review  and 
action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

 
 
 
 
 
  
 National Medical Director

2nd Floor 
2 Redman Place 
London 
E20 1JQ 
United Kingdom 

+44 (0)300 323 0140 

18 March 2025 

Ms Elizabeth Gray 
Area Coroner for Cambridgeshire and Peterborough 

Sent via email: 

Our reference: 

Dear Ms Gray,    

Re: Regulation 28 Prevention of Future Deaths Report in respect of Amelia Alexandra 
Anuszka Ridout 

I write in response to your regulation 28 report, dated 11 February 2025, regarding the very 
sad death of Amelia Ridout. I would like to express my sincere condolences to Amelia’s family.   

We would like to thank you for including NICE in this important report. We have reflected on 
the circumstances surrounding Amelia’s death and the concerns raised. We note your request 
to consider the development and publication of a national guideline and standard operating 
procedure  for  carrying  out  Bone  Marrow  Aspirate  (BMA)  and  trephine  biopsy  to  include 
recommended methodology.  

This is a truly tragic outcome from a widely used intervention that is essential in haematological 
practice.  Bleeding  due  to  vascular  injuries  is  recognised  as  a  rare,  but  possible  adverse 
outcome of the procedure. NICE have not published any specific procedural guidance on bone 
marrow aspirate and trephine biopsy however, NICE guidance refers to the need to carry out 
the procedure for diagnosis1. NICE are not asked to develop guidance on all conditions and 
our recommendations do not cover all clinical circumstances. Our guidance focuses on the 
management and treatment of conditions and although we may outline recommendations on 
when  an  investigation  or  diagnostic  test  is  necessary,  it  is  not  within  our  remit  to  produce 
detailed guidance on how clinicians should carry out a standard diagnostic procedure. 

NICE is not the only organisation that produces guidance and standard operating procedures; 
we  would  expect  that  hospital  trusts  or  individual  clinicians  also  follow  guidance  from 
professional  bodies,  Royal  Colleges  and  local  care  pathways  developed by  commissioners 
such as integrated care boards and NHS England.   

1 Haematological cancers: improving outcomes 

 
 
 
 
 
 
 
 
 
 We note that you have also written to the British Society for Haematology (BSH) and NHS 
England  and  as  part  of  our  process,  our  consultant  clinical  advisors  have  been  in 
communication with these two organisations and will contribute as needed in the production 
of a good practice paper for bone marrow aspirate and trephine biopsy, which is being led by 
the BSH. 

NICE has offered to work with the BSH on the development of this paper, ensuring that any 
references to NICE guidance are included where applicable. Through our organisation-wide 
approach to prioritisation and topic selection, NICE’s prioritisation board could then consider 
any new recommendations made by the BSH guidance and whether they require updates to 
existing  guidance  or  development  of  new  NICE  guidance  on  this  topic  if  this  is  considered 
appropriate. 

I hope this response has helped outline our role and the placement of our guidance within the 
wider  healthcare  system.  We  will  continue  to  liaise  with  colleagues  at  the  BSH  and  NHS 
England on the development of an appropriately placed guidance document if appropriate. I 
would like to reiterate my sincere condolences to Amelia’s family.   

Yours sincerely, 

Chief Executive     

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