Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0489, written 29 Sep 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Sep 2025 |
|---|---|
| Reference | 2025-0489 |
| Deceased | Mohammad Asghar |
| Coroner | Graeme Irvine |
| Coroner area | East London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Barts Health NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
MR G IRVINE SENIOR CORONER EAST LONDON CORONERS COURT 124 Queens Road Walthamstow, E17 8QP REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Trust , Chief Executive Officer, Barts Health NHS Foundation 1 CORONER I am Graeme Irvine, senior coroner, for the coroner area of East London 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 17th September 2024, this court commenced an investigation into the death of Mohammad Ali Asghar aged 82 years. The investigation concluded at the end of the inquest on 14/05/2025. The court returned a narrative conclusion. “Mohammad Ali Asghar died in hospital on 14th September 2024. Dr Asghar was admitted to hospital with shortness of breath and fluid overload on 8th September 2024. During treatment, Dr Asghar suffered a cardiac arrest caused by, haemorrhagic pericarditis, heart failure and an iatrogenic injury to his bladder caused during necessary catheterisation." Mr Asghar’s medical cause of death was determined as; 1 1a Cardiac arrest 1b Haemorrhagic Pericarditis, Iatrogenic bladder haemorrhage 1c Decompensated heart failure II Hypertension, Cirrhotic Liver (Cryptogenic), Old Myocardial Infarction CIRCUMSTANCES OF THE DEATH Mr Asghar was admitted to hospital on 8/9/24 with worsening shortness of breath on exertion. Following tests it was identified that Mr Asghar was suffering from decompensated heart failure with hypervolaemic hyponatraemia (low sodium caused by fluid overload), deranged liver function and constipation. Mr Asghar treatment included intravenous diuresis to offload fluid and he was commenced on a fluid restriction, daily bloods and weights were requested. A catheter was inserted on 13/9/24 to help monitor fluid input and output monitoring. Following catheterisation there was some haematuria with clots (blood in the urine) and the plan was to replace the catheter. Following removal of the catheter the patient went to the toilet to pass urine and collapsed. Mr Asghar went into cardiac arrest and CPR was unsuccessful. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – 1. A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice. In this case the trust’s Datix incident reporting system, morbidity and mortality meeting process and PSIRF procedure were inadequate. 2. Despite concerns being raised by a medical examiner, a coroner’s court finding that an iatrogenic injury was contributory to death, and an express direction from this court for the case to be reviewed, no patient safety framework investigation has occurred. 3. Correspondence received from the Trust sent three months after the inquest that seeks to explain why a PSRF investigation was not undertaken in this case betrays the fact that senior governance staff at the Trust still do not understand NHS England guidance on what should trigger a patient safety investigation. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 23rd November 2025 I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out 2 the timetable for action. Otherwise, you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons the family of Mr Asghar, the Care Quality Commission, NHS England and to the local Director of Public Health who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response. 9 [DATE] 29/09/2025 [SIGNED BY CORONER] 3
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Trust Headquarters Executive Offices Ground Floor Pathology and Pharmacy Building The Royal London Hospital 80 Newark Street London E1 2ES Date: 19 November 2025 Private & Confidential East London Coroners Court Queens Road Walthamstow London E17 8QP Dear HM Coroner, Thank you for your letter dated 29 September 2005 following the inquest of Mr Mohammed Ali Asghar. The Whipps Cross Executive team acknowledge that you provided the hospital with an opportunity to reflect on the decision not to commission a learning response and only issued a PFD when the Trust did not follow your express direction in the matter and submitted the rationale for this decision 3 months after the inquest. The Prevention of Future Death report has been reviewed at Whipps Cross Divisional and Hospital Boards to agree actions that will have an impact across the Barts Health group. The PFD and response will be shared at Trust Safety Committee, with National Health Service England (NHSE), the Care Quality Commission (CQC) and the North East London Integrated Care Board. Your concerns 1. A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Incident Response Framework. This omission gives rise to a concern that future deaths may follow due to an inability to on the part of the Trust to identify, reflect upon, and remediate sub-optimal practice, in this case the Trust’s Datix incident reporting system, morbidity and mortality meeting process and PSIRF procedure were inadequate. 2. Despite concerns being raised by a medical examiner, a coroner’s court finding that an iatrogenic injury was contributory to death, and an express direction from this court for the case to be reviewed, no patient safety framework investigation has occurred. 3. Correspondence received from the Trust, sent three months after the inquest that seeks to explain why a PSIRF investigation was not undertaken in this case betrays the fact that senior governance staff at the Trust still do not understand NHS guidance on what should trigger a patient safety investigation. Our response We acknowledge the coroner’s concerns regarding the absence of a Patient Safety Incident Investigation (PSII) and the subsequent Prevention of Future Deaths (PFD) notice issued to the organisation. We recognise the importance of this feedback and are committed to ensuring that our governance and decision-making processes identifying and commissioning investigations under the Patient Safety Incident Response Framework (PSIRF) are robust, transparent, and consistently applied. for While the governance process followed at the time reflected expert input and the information then available, we accept our assessment lacked necessary rigour leading to the decision of not requesting a PSIRF learning response. We acknowledge the need to strengthen our approach to ensure that decisions are informed by all relevant sources, including outputs from morbidity and mortality reviews, concerns raised by families/carers and the coroner. To support this, Barts Health is in the process of commissioning an Independent Review of our governance processes with comprehensive terms of reference which will include review of our decision-making at Patient Safety Incident Review Meeting (PSIRM) relating to the learning responses under PSIRF. This review will examine the criteria and thresholds used to determine when a PSII or alternative learning response is required, ensuring these are clearly defined, consistently applied, and responsive to emerging information or stakeholder concerns. The outcomes of this review will inform refinements to our local processes and provide additional assurance that lessons are identified and acted upon in a timely and proportionate way. We remain committed to a culture of openness, reflection, and continuous learning, and we will share the findings and actions arising from this review with relevant stakeholders, including the coroner. If you have any queries, please do not hesitate to contact me. Yours sincerely Group Chief Medical Officer Barts Health NHS Trust
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