Abdulrahman Alajmi
PFD Report
Partially Responded
Ref: 2025-0192
Coroner's Concerns (AI summary)
UK hospitals lack a set procedure for accepting international patients, often receiving individuals sicker than anticipated due to inaccurate information and insufficient systems for safe transfer and treatment.
View full coroner's concerns
1. In the course of the evidence it was confirmed that there is no set procedure regarding the acceptance by hospitals in the UK of patients for treatment from other countries.
2. It was stated in evidence that patients often arrive in a substantially different (often worse) condition to that described to the receiving clinicians when they accepted the referral and agreed that they were able to provide treatment. This means that UK health providers may receive for treatment individuals who are more unwell than anticipated, potentially requiring expertise that is not held by the receiving treatment providers (albeit in this case they had an ICU team who were able to provide the necessary treatment).
3. The evidence provided showed that it is up to each individual hospital to determine whether they are willing and able to accept a referral and agree the process for transfer of the patient. The evidence indicated that that process is not uniform and relies heavily on the accuracy of the information received from the referring medical staff, as well as it being appropriately updated should circumstances change.
4. The evidence indicated that it is the decision of the medical staff in the country that the patient is coming from whether, and with what medical support, a patient can travel to come to the UK. That is not within the control of the UK. However, the process by which hospitals in the UK accept referrals from other countries and the provision of visas (and any conditions attached to them) for those individuals to enter the UK for that treatment is within the control of the UK.
5. The evidence showed an absence of systems or structures to ensure that patients arriving in the UK for medical treatment are able to be received (by the ambulance transferring them and the hospital treating them) safely and be properly treated: with a full understanding of the accurate and up to date medical position.
6. The evidence leads to a concern that patients are being put at risk, leading to the possibility of future deaths occurring, and that the UK's health services are put under unnecessary strain by receiving patients who are more unwell than anticipated when a referral is accepted.
7. I consider action should be taken to investigate this issue and consider what, if any, systems can and should be implemented, or steps can and should be taken, to protect patients, and mitigate the risks to and impact on both patients and the UK's health services.
2. It was stated in evidence that patients often arrive in a substantially different (often worse) condition to that described to the receiving clinicians when they accepted the referral and agreed that they were able to provide treatment. This means that UK health providers may receive for treatment individuals who are more unwell than anticipated, potentially requiring expertise that is not held by the receiving treatment providers (albeit in this case they had an ICU team who were able to provide the necessary treatment).
3. The evidence provided showed that it is up to each individual hospital to determine whether they are willing and able to accept a referral and agree the process for transfer of the patient. The evidence indicated that that process is not uniform and relies heavily on the accuracy of the information received from the referring medical staff, as well as it being appropriately updated should circumstances change.
4. The evidence indicated that it is the decision of the medical staff in the country that the patient is coming from whether, and with what medical support, a patient can travel to come to the UK. That is not within the control of the UK. However, the process by which hospitals in the UK accept referrals from other countries and the provision of visas (and any conditions attached to them) for those individuals to enter the UK for that treatment is within the control of the UK.
5. The evidence showed an absence of systems or structures to ensure that patients arriving in the UK for medical treatment are able to be received (by the ambulance transferring them and the hospital treating them) safely and be properly treated: with a full understanding of the accurate and up to date medical position.
6. The evidence leads to a concern that patients are being put at risk, leading to the possibility of future deaths occurring, and that the UK's health services are put under unnecessary strain by receiving patients who are more unwell than anticipated when a referral is accepted.
7. I consider action should be taken to investigate this issue and consider what, if any, systems can and should be implemented, or steps can and should be taken, to protect patients, and mitigate the risks to and impact on both patients and the UK's health services.
Responses
Noted
The Department of Health and Social Care acknowledges the concerns about systems for safely receiving overseas patients seeking medical treatment in the UK. The response outlines existing regulatory oversight by the CQC and notes the importance of accurate medical information, but does not commit to specific action. (AI summary)
The Department of Health and Social Care acknowledges the concerns about systems for safely receiving overseas patients seeking medical treatment in the UK. The response outlines existing regulatory oversight by the CQC and notes the importance of accurate medical information, but does not commit to specific action. (AI summary)
View full response
Dear Ms Oakley,
Thank you for the Regulation 28 report of 16 April 2025 sent to the Secretary of State / the Department of Health and Social Care about the death of Abdulrahman AlAjmi. I am replying as the Minister with responsibility for elective care.
Firstly, I would like to say how saddened I was to read of the circumstances of Mr AlAjmi’s death and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for the delay in responding to this matter. Thank you for the additional time provided to the department to provide a response to the concerns raised in the report.
The report raises concerns over an absence of systems or structures to ensure that patients arriving in the United Kingdom for medical treatment can be safely received and be properly treated.
In preparing this response, my officials have made enquiries with NHS England, the Care Quality Commission and the Home Office to ensure we adequately address your concerns.
Suggested reply
The Private Healthcare Information Network (PHIN) report that over 10,000 non-UK nationals were treated in the UK through privately funded treatment in independent sector and NHS facilities in 2023, with most episodes of care delivered without incident. Most independent healthcare service providers must register with the Care Quality Commission (CQC). This would include those providers running independent hospitals. The CQC have a quality statement under their assessment framework ‘Safe systems, pathways and transitions,’ which assesses whether safety and continuity of care is a priority throughout people’s care journey. This happens through a collaborative, joined-up approach to safety that involves patients along with staff and other partners in their care. The approach includes referrals, admissions and discharge, and where people are moving between services.
During an assessment the CQC considers how risks to patients are identified and managed across their care journey. The CQC look for evidence of effective oversight to keep people safe. The CQC would also look at provider policies in relation to their admission criteria to ensure they are clear about what type of health conditions and co- morbidities they can and cannot admit into their service. In this instance it is clear the provider in England with whom treatment was arranged received misleading information from a third-party medical professional based in a different jurisdiction. Specialist care (including private care) in England usually requires a detailed medical history, referral letter, relevant test results and informed consent. Private hospitals accepting referrals for patients from overseas must adhere to clinical and regulatory safety guidelines shaped by NHS England, the Care Quality Commission (CQC), and the British Medical Association (BMA). There are also specific protocols and partnerships in place due to the formal healthcare agreements between the Kuwaiti government and certain UK private providers. Ultimately, it is important that all providers accepting incoming patients can as far as possible, assure themselves of the on the accuracy of medical information used in decisions to admit. As noted in the report, there is limited recourse for any provider, NHS or independent, to undertake proceedings against a medical professional based in a third country. The private facility accepting the referral did have the facilities in place to provide the intensive care required in these circumstances. Although not relevant in this case , cost recovery procedures exist where patients who are overseas visitors are admitted as inpatients following an initial presentation at an accident and emergency (A&E) facility, ensuring the NHS recoups the costs of the services it provides.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
Thank you for the Regulation 28 report of 16 April 2025 sent to the Secretary of State / the Department of Health and Social Care about the death of Abdulrahman AlAjmi. I am replying as the Minister with responsibility for elective care.
Firstly, I would like to say how saddened I was to read of the circumstances of Mr AlAjmi’s death and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for the delay in responding to this matter. Thank you for the additional time provided to the department to provide a response to the concerns raised in the report.
The report raises concerns over an absence of systems or structures to ensure that patients arriving in the United Kingdom for medical treatment can be safely received and be properly treated.
In preparing this response, my officials have made enquiries with NHS England, the Care Quality Commission and the Home Office to ensure we adequately address your concerns.
Suggested reply
The Private Healthcare Information Network (PHIN) report that over 10,000 non-UK nationals were treated in the UK through privately funded treatment in independent sector and NHS facilities in 2023, with most episodes of care delivered without incident. Most independent healthcare service providers must register with the Care Quality Commission (CQC). This would include those providers running independent hospitals. The CQC have a quality statement under their assessment framework ‘Safe systems, pathways and transitions,’ which assesses whether safety and continuity of care is a priority throughout people’s care journey. This happens through a collaborative, joined-up approach to safety that involves patients along with staff and other partners in their care. The approach includes referrals, admissions and discharge, and where people are moving between services.
During an assessment the CQC considers how risks to patients are identified and managed across their care journey. The CQC look for evidence of effective oversight to keep people safe. The CQC would also look at provider policies in relation to their admission criteria to ensure they are clear about what type of health conditions and co- morbidities they can and cannot admit into their service. In this instance it is clear the provider in England with whom treatment was arranged received misleading information from a third-party medical professional based in a different jurisdiction. Specialist care (including private care) in England usually requires a detailed medical history, referral letter, relevant test results and informed consent. Private hospitals accepting referrals for patients from overseas must adhere to clinical and regulatory safety guidelines shaped by NHS England, the Care Quality Commission (CQC), and the British Medical Association (BMA). There are also specific protocols and partnerships in place due to the formal healthcare agreements between the Kuwaiti government and certain UK private providers. Ultimately, it is important that all providers accepting incoming patients can as far as possible, assure themselves of the on the accuracy of medical information used in decisions to admit. As noted in the report, there is limited recourse for any provider, NHS or independent, to undertake proceedings against a medical professional based in a third country. The private facility accepting the referral did have the facilities in place to provide the intensive care required in these circumstances. Although not relevant in this case , cost recovery procedures exist where patients who are overseas visitors are admitted as inpatients following an initial presentation at an accident and emergency (A&E) facility, ensuring the NHS recoups the costs of the services it provides.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
Noted
NHS England states that the concerns raised in the report do not fall within their remit, as the receiving hospital was private, but they have made North West London Integrated Care Board aware of the concerns. They also highlight existing national guidance on the repatriation of ill patients from overseas. (AI summary)
NHS England states that the concerns raised in the report do not fall within their remit, as the receiving hospital was private, but they have made North West London Integrated Care Board aware of the concerns. They also highlight existing national guidance on the repatriation of ill patients from overseas. (AI summary)
View full response
Dear Ms Oakley, Re: Regulation 28 Report to Prevent Future Deaths – Abdulrahman AlAjmi who died on 7 August 2024.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 16 April 2025 concerning the death of Abdulrahman AlAjmi on 7 August 2024. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Abdulrahman’s family and loved ones. NHS England are keen to assure the family and yourself that the concerns raised about Abdulrahman’s care have been listened to and reflected upon.
Your Report raises concerns over there being no set procedures, systems or structures regarding the acceptance by hospitals in the UK of patients for treatment from other countries, and that patients often arrive in a condition substantially different to that described to the receiving clinicians. You have raised that this leads to the concern that patients are being put at risk and the UK’s health services are being put under unnecessary strain.
The concerns raised in your Report do not sit within NHS England’s remit. NHS England notes that the Coroner has also addressed your Report to the Department of Health and Social Care (DHSC) and the Foreign, Commonwealth and Development Office (FCDO) who are the more appropriate organisations to respond to your concerns. Where we are able to, NHS England will be happy to support these organisations in addressing the concerns raised.
While we note that, in this case, the receiving hospital was private and not under NHS jurisdiction, it is currently the case that any acceptance of a foreign patient by an NHS hospital would be subject to local procedures. We have therefore ensured that North West London Integrated Care Board (NWL ICB), the host ICB for the London Clinic, are aware of Abdulrahman’s case and the concerns raised in your Report for assurance purposes.
There is also existing national guidance available on the repatriation of ill patients from overseas, produced by the Faculty of Intensive Care Medicine (FICM) and the Intensive Care Society (ICS), which you may find useful:
• Transfer_of_Critically_Ill_Adult.pdf Co-National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
4 June 2025
• Intensive Care Society | Guidance for repatriation of critically ill patients 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 Abdulrahman, 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.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 16 April 2025 concerning the death of Abdulrahman AlAjmi on 7 August 2024. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Abdulrahman’s family and loved ones. NHS England are keen to assure the family and yourself that the concerns raised about Abdulrahman’s care have been listened to and reflected upon.
Your Report raises concerns over there being no set procedures, systems or structures regarding the acceptance by hospitals in the UK of patients for treatment from other countries, and that patients often arrive in a condition substantially different to that described to the receiving clinicians. You have raised that this leads to the concern that patients are being put at risk and the UK’s health services are being put under unnecessary strain.
The concerns raised in your Report do not sit within NHS England’s remit. NHS England notes that the Coroner has also addressed your Report to the Department of Health and Social Care (DHSC) and the Foreign, Commonwealth and Development Office (FCDO) who are the more appropriate organisations to respond to your concerns. Where we are able to, NHS England will be happy to support these organisations in addressing the concerns raised.
While we note that, in this case, the receiving hospital was private and not under NHS jurisdiction, it is currently the case that any acceptance of a foreign patient by an NHS hospital would be subject to local procedures. We have therefore ensured that North West London Integrated Care Board (NWL ICB), the host ICB for the London Clinic, are aware of Abdulrahman’s case and the concerns raised in your Report for assurance purposes.
There is also existing national guidance available on the repatriation of ill patients from overseas, produced by the Faculty of Intensive Care Medicine (FICM) and the Intensive Care Society (ICS), which you may find useful:
• Transfer_of_Critically_Ill_Adult.pdf Co-National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
4 June 2025
• Intensive Care Society | Guidance for repatriation of critically ill patients 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 Abdulrahman, 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.
Noted
The FCDO believes a response sits outside of their remit, and is more appropriate for the Department of Health and Social Care. (AI summary)
The FCDO believes a response sits outside of their remit, and is more appropriate for the Department of Health and Social Care. (AI summary)
View full response
Dear , Apologies for the delay in responding. The Coroner Liaison OƯicer in our Consular Directorate had passed a response to the Parliamentary Correspondence Team (PCT), who monitor this mailbox, on the 2nd June. Unfortunately, the case manager in PCT had by that point left the FCDO, so the response was never passed on. Their response was as follows: [BEGINS] I don’t believe a response sits within my remit and seems more for the Health Department [DHSC]. It’s about people travelling to the UK for medical procedures in a worse condition than anticipated. This would be for [DHSC] to liaise with the Health Team in the country who has sent the referral to determine if they are well enough to travel. [ENDS] Regards, Foreign, Commonwealth, and Development OƯice
Sent To
- Department of Health and Social Care
- Foreign, Commonwealth and Development Office
- Home Office
- NHS England
Response Status
Linked responses
3 of 4
56-Day Deadline
11 Jun 2025
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 24 August 2024 the Coroner commenced an investigation into the death of Abdulrahman ALAJMI. The investigation concluded at the end of the inquest on 15 April 2025. The conclusion of the inquest was: Natural Causes exacerbated by travel for treatment
Circumstances of the Death
The Medical Certificate of the Cause stated the following: la) Multiorgan Failure b)septic shock (Acinetobacter baumennii) c) infected left leg wound and ischaemic left leg 2 ischaemic heart disease, peripheral vascular disease On 7 August 2024 at the London Clinic, 20 Devonshire Place, London, Abdulrahman AlAjmi died from multiorgan failure (as set out in the medical cause of death). He had arrived in the UK for medical treatment on 24 July 2024 in a much poorer medical condition than had been outlined by the referring hospital, as he had deteriorated three days before he flew without the receiving hospital being notified of that. He was on a ventilator and bleeding, neither of which had been indicated to the receiving hospital or ambulance which transferred him from the plane to the hospital. Despite appropriate medical treatment being given in the UK, he did not recover. I found that it is probable that the flight contributed to his death by exacerbating his very serious pre-existing medical conditions. The evidence also indicated that patients who come to the UK for treatment from overseas often arrive in a worse condition than anticipated, which means that receiving hospitals and ambulances may not always be equipped to treat the patient appropriately (as they have accepted the referral on the basis of a different medical condition). 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 will 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. In the course of the evidence it was confirmed that there is no set procedure regarding the acceptance by hospitals in the UK of patients for treatment from other countries.
2. It was stated in evidence that patients often arrive in a substantially different (often worse) condition to that described to the receiving clinicians when they accepted the referral and agreed that they were able to provide treatment. This means that UK health providers may receive for treatment individuals who are more unwell than anticipated, potentially requiring expertise that is not held by the receiving treatment providers (albeit in this case they had an ICU team who were able to provide the necessary treatment).
3. The evidence provided showed that it is up to each individual hospital to determine whether they are willing and able to accept a referral and agree the process for transfer of the patient. The evidence indicated that that process is not uniform and relies heavily on the accuracy of the information received from the referring medical staff, as well as it being appropriately updated should circumstances change.
4. The evidence indicated that it is the decision of the medical staff in the country that the patient is coming from whether, and with what medical support, a patient can travel to come to the UK. That is not within the control of the UK. However, the process by which hospitals in the UK accept referrals from other countries and the provision of visas (and any conditions attached to them) for those individuals to enter the UK for that treatment is within the control of the UK.
5. The evidence showed an absence of systems or structures to ensure that patients arriving in the UK for medical treatment are able to be received (by the ambulance transferring them and the hospital treating them) safely and be properly treated: with a full understanding of the accurate and up to date medical position.
6. The evidence leads to a concern that patients are being put at risk, leading to the possibility of future deaths occurring, and that the UK's health services are put under unnecessary strain by receiving patients who are more unwell than anticipated when a referral is accepted.
7. I consider action should be taken to investigate this issue and consider what, if any, systems can and should be implemented, or steps can and should be taken, to protect patients, and mitigate the risks to and impact on both patients and the UK's health services. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 11 June 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: son of Mr Abdulrahman AlAjmi The London Clinic I have also sent it to The Independent Healthcare Provider Network, the Faculty of Intensive Care Medicine and the Intensive Care Society, who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. She 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 by the Chief Coroner. 16 April 2025 Signature: Ellie Oakley Oakley Assistant Coroner for Inner West London
1. In the course of the evidence it was confirmed that there is no set procedure regarding the acceptance by hospitals in the UK of patients for treatment from other countries.
2. It was stated in evidence that patients often arrive in a substantially different (often worse) condition to that described to the receiving clinicians when they accepted the referral and agreed that they were able to provide treatment. This means that UK health providers may receive for treatment individuals who are more unwell than anticipated, potentially requiring expertise that is not held by the receiving treatment providers (albeit in this case they had an ICU team who were able to provide the necessary treatment).
3. The evidence provided showed that it is up to each individual hospital to determine whether they are willing and able to accept a referral and agree the process for transfer of the patient. The evidence indicated that that process is not uniform and relies heavily on the accuracy of the information received from the referring medical staff, as well as it being appropriately updated should circumstances change.
4. The evidence indicated that it is the decision of the medical staff in the country that the patient is coming from whether, and with what medical support, a patient can travel to come to the UK. That is not within the control of the UK. However, the process by which hospitals in the UK accept referrals from other countries and the provision of visas (and any conditions attached to them) for those individuals to enter the UK for that treatment is within the control of the UK.
5. The evidence showed an absence of systems or structures to ensure that patients arriving in the UK for medical treatment are able to be received (by the ambulance transferring them and the hospital treating them) safely and be properly treated: with a full understanding of the accurate and up to date medical position.
6. The evidence leads to a concern that patients are being put at risk, leading to the possibility of future deaths occurring, and that the UK's health services are put under unnecessary strain by receiving patients who are more unwell than anticipated when a referral is accepted.
7. I consider action should be taken to investigate this issue and consider what, if any, systems can and should be implemented, or steps can and should be taken, to protect patients, and mitigate the risks to and impact on both patients and the UK's health services. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 11 June 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: son of Mr Abdulrahman AlAjmi The London Clinic I have also sent it to The Independent Healthcare Provider Network, the Faculty of Intensive Care Medicine and the Intensive Care Society, who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. She 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 by the Chief Coroner. 16 April 2025 Signature: Ellie Oakley Oakley Assistant Coroner for Inner West London
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.