13 Aug 2018 Flora Marion BABER · Prevention of Future Deaths report Inner North London
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Concerns raised 10 Failure to provide appropriately pureed food and eating assistance View source Failure to provide requested toileting assistance View source Delays in treating oral thrush View source Failure of allocated ward staff to remain awake and attentive View source Delays in referral to the speech and language team View source Inaccurate recording of patients’ continence status View source Failure to recognise opioid sensitivity when prescribing or administering opioids View source Failure to record opioid sensitivity as an alert across care records View source Failure to identify and act on swallowing problems without family prompting View source Failure to keep drinking fluids within reach View source See 7 more concerns
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Flora Marion BABER · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Flora Marion Baber was admitted to the Royal Free Hospital from Compton Lodge Care Home on 25 January 2018 with increased confusion, slurred speech and difficulty breathing, and died there about a month later. Concerns included inadequate access to fluids, inappropriate food and eating assistance, delays in speech and language referral and treatment of oral thrush, an apparently sleeping staff member, inappropriate responses to toileting requests, and failure to record her opioid sensitivity across healthcare settings.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Adelaide Medical Centre, London; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriately pureed food and eating assistance
Wider context from the report “1. Whilst record keeping showed Dr Baber as having been given appropriate food and drink whilst on the ward in hospital, I heard that sometimes her nearest fluid was out of her reach on a bedside table too far from the bed.
Also, she did not always receive appropriately pureed food or the assistance that she needed to eat .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Adelaide Medical Centre, London; that does not assign responsibility.
PFD Monitor interpretation Failure to provide requested toileting assistance
Wider context from the report “4. Dr Baber was noted in the medical records as being doubly incontinent. However, family members told me that she was not incontinent.
Rather, when she asked for assistance to go to the toilet or to use a bedpan (she had poor mobility), a healthcare assistant told her that staff were busy , she was wearing an incontinence pad, and she should use that instead .
I was shocked to hear this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Adelaide Medical Centre, London; that does not assign responsibility.
PFD Monitor interpretation Delays in treating oral thrush
Wider context from the report “2. There was a delay in referring Dr Baber to the speech and language team and in treating her oral thrush .
Most significantly, I heard evidence that it was only when family members pointed out a problem such as pain on swallowing, that staff acted to deal with this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Adelaide Medical Centre, London; that does not assign responsibility.
PFD Monitor interpretation Failure of allocated ward staff to remain awake and attentive
Wider context from the report “3. Family members told me that at one point, they found the member of staff allocated to Dr Baber’s bay sitting in a chair apparently asleep .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Adelaide Medical Centre, London; that does not assign responsibility.
PFD Monitor interpretation Delays in referral to the speech and language team
Wider context from the report “2. There was a delay in referring Dr Baber to the speech and language team and in treating her oral thrush.
Most significantly, I heard evidence that it was only when family members pointed out a problem such as pain on swallowing, that staff acted to deal with this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Adelaide Medical Centre, London; that does not assign responsibility.
PFD Monitor interpretation Inaccurate recording of patients’ continence status
Wider context from the report “4. Dr Baber was noted in the medical records as being doubly incontinent. However, family members told me that she was not incontinent.
Rather, when she asked for assistance to go to the toilet or to use a bedpan (she had poor mobility), a healthcare assistant told her that staff were busy, she was wearing an incontinence pad, and she should use that instead.
I was shocked to hear this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Adelaide Medical Centre, London; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise opioid sensitivity when prescribing or administering opioids
Wider context from the report “5. Dr Baber had a sensitivity to opioids, such that her family noted a direct correlation between episodes of sickness and vomiting, and the administration of opioid medication.
This had been recognised and recorded during earlier admissions to the Royal Free, and family had discussed with staff at the care home.
However, it was not recorded as an alert on her hospital notes, or on her general practitioner notes, or on the care home notes.
At the very end of Dr Baber’s life, the benefit of pain relief was thought to outweigh the side effects of opiates, but before then her sensitivity was simply not recognised .
This caused her discomfort and distress, and in another case could have fatal consequences.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Adelaide Medical Centre, London; that does not assign responsibility.
PFD Monitor interpretation Failure to record opioid sensitivity as an alert across care records
Wider context from the report “5. Dr Baber had a sensitivity to opioids, such that her family noted a direct correlation between episodes of sickness and vomiting, and the administration of opioid medication.
This had been recognised and recorded during earlier admissions to the Royal Free, and family had discussed with staff at the care home.
However, it was not recorded as an alert on her hospital notes, or on her general practitioner notes, or on the care home notes .
At the very end of Dr Baber’s life, the benefit of pain relief was thought to outweigh the side effects of opiates, but before then her sensitivity was simply not recognised.
This caused her discomfort and distress, and in another case could have fatal consequences.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Adelaide Medical Centre, London; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and act on swallowing problems without family prompting
Wider context from the report “2. There was a delay in referring Dr Baber to the speech and language team and in treating her oral thrush.
Most significantly, I heard evidence that it was only when family members pointed out a problem such as pain on swallowing, that staff acted to deal with this .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Adelaide Medical Centre, London; that does not assign responsibility.
PFD Monitor interpretation Failure to keep drinking fluids within reach
Wider context from the report “1. Whilst record keeping showed Dr Baber as having been given appropriate food and drink whilst on the ward in hospital, I heard that sometimes her nearest fluid was out of her reach on a bedside table too far from the bed .
Also, she did not always receive appropriately pureed food or the assistance that she needed to eat.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discussed appropriate coding of clinically significant opioid sensitivities in GP notes.
Verbatim wording from the response “• 18/09/2019: Meeting ████████, ████████ (Managing partner) and ████████ (Practice Manager); to discuss how the sensitivity to opioids could have been coded appropriately in the GP notes” Source location 2018-0299-Response-by-Adelaide-Medical-Centre
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Shared learning on recording opioid sensitivities with Royal Free Hospital and Compton Lodge representatives.
Verbatim wording from the response “• 18/09/2019: Meeting ████████████████████ (Royal Free Geriatrician), ████████ Compton Lodge Dept Care Home Manager; To share Adelaide’s learning and see how this may support recording at the Royal Free and Compton Lodge.” Source location 2018-0299-Response-by-Adelaide-Medical-Centre
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recorded the learning in an internal significant event and shared it with all practice clinicians, including the opioid-sensitivity alerting process.
Verbatim wording from the response “• This reflection/learning has been captured in a significant event and shared with the other clinicians in the practice.” Source location 2018-0299-Response-by-Adelaide-Medical-Centre
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Systematic alerting of opioid sensitivities between hospital and GP practice cannot be implemented until the planned new IT system is available.
Verbatim wording from the response “• RFH felt it was not possible to consider a more systematic alerting of sensitivities/allergies between RFH to GP practice until the new IT system (planned for ~12mths) is implemented. Therefore, no process change to be considered at this time.” Source location 2018-0299-Response-by-Adelaide-Medical-Centre
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations