Mohammad Asghar
PFD Report
All Responded
Ref: 2025-0489
All 1 response received
· Deadline: 23 Nov 2025
Coroner's Concerns (AI summary)
The Trust's governance failed to investigate a serious incident, despite multiple triggers and court orders, revealing a misunderstanding of patient safety guidelines and an inability to learn from adverse events.
View full coroner's 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 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.
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.
Responses
Action Planned
Barts Health acknowledges failures in governance and is commissioning an Independent Review of governance processes related to Patient Safety Incident Response Framework (PSIRF), including decision-making at Patient Safety Incident Review Meetings (PSIRM). (AI summary)
Barts Health acknowledges failures in governance and is commissioning an Independent Review of governance processes related to Patient Safety Incident Response Framework (PSIRF), including decision-making at Patient Safety Incident Review Meetings (PSIRM). (AI summary)
View full response
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.
Trust Headquarters Executive Offices Ground Floor
Pathology and Pharmacy Building The Royal London Hospital 80 Newark Street London E1 2ES
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 for identifying and commissioning investigations under the Patient Safety Incident Response Framework (PSIRF) are robust, transparent, and consistently applied.
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.
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.
Trust Headquarters Executive Offices Ground Floor
Pathology and Pharmacy Building The Royal London Hospital 80 Newark Street London E1 2ES
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 for identifying and commissioning investigations under the Patient Safety Incident Response Framework (PSIRF) are robust, transparent, and consistently applied.
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.
Sent To
Response Status
Linked responses
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56-Day Deadline
23 Nov 2025
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
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; 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.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.