10 Mar 2026 Sheila Creagan · Prevention of Future Deaths report East London
View report summary
Concerns raised 5 Failure to investigate deaths under the Patient Safety Framework View source Failure to accurately determine and record the cause of death View source Failure to diagnose infective endocarditis View source Failure to monitor developing heart failure during inpatient treatment View source Failure to investigate the source of a progressing infection after pneumonia resolves View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 4
Action
Require multidisciplinary clinical review of relevant coronial cases, including cases involving concerns about diagnosis, deterioration, monitoring, treatment or missed opportunities.
Stated completedThe respondent said that this action was complete when they made their response on 18 March 2026. View source
Action
Operate the Coroner’s Case Review Meeting as a formal governance mechanism for multidisciplinary oversight of inquest and coronial cases.
Stated completedThe respondent said that this action was complete when they made their response on 18 March 2026. View source
Action
Clarify in governance arrangements that PSIRF is one learning mechanism and not the Trust’s sole route for reviewing deaths or responding to coronial concerns.
Stated completedThe respondent said that this action was complete when they made their response on 18 March 2026. View source
Action
Use multiple review routes, including MDT, mortality, complaints, clinician reflection and CCRM reviews, rather than relying solely on PSIRF.
Stated completedThe respondent said that this action was complete when they made their response on 18 March 2026. View source See 1 more action
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AI-generated summary
Sheila Creagan · 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
Sheila Creagan, an 81-year-old woman with heart failure, underwent emergency abdominal surgery in February 2025 and was later admitted with breathing difficulties, anaemia and a suspected gastrointestinal bleed. She died in hospital on 17 March 2025; the inquest determined that untreated and undiagnosed infective endocarditis caused her death. Concerns included the failure to investigate the source of her worsening infection, the missed diagnosis of infective endocarditis, inadequate monitoring of her heart failure, and the decision not to conduct a Patient Safety Framework investigation.
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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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate deaths under the Patient Safety Framework
Wider context from the report “1. BHRUT chose not to investigate this case as part of NHS England’s Patient Safety Framework . Mrs Creagan’s death ought to have been subject to such an investigation .
Decisions were reached at two clinical governance meetings that meaningful learning could not flow from a governance investigation into the circumstances of Mrs Creagan’s care . Such decisions appear to be incongruous with;
a. The inaccurate cause of death initially offered by the Trust,
b. The failure to investigate the seat of Mrs Creagan’s burgeoning infection after her pneumonia resolved.
c. The missed diagnosis of infective endocarditis,
d. The failure to monitor the development of Mrs Creagan’s heart failure during her inpatient treatment.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately determine and record the cause of death
Wider context from the report “1. BHRUT chose not to investigate this case as part of NHS England’s Patient Safety Framework. Mrs Creagan’s death ought to have been subject to such an investigation.
Decisions were reached at two clinical governance meetings that meaningful learning could not flow from a governance investigation into the circumstances of Mrs Creagan’s care. Such decisions appear to be incongruous with;
a. The inaccurate cause of death initially offered by the Trust ,
b. The failure to investigate the seat of Mrs Creagan’s burgeoning infection after her pneumonia resolved.
c. The missed diagnosis of infective endocarditis,
d. The failure to monitor the development of Mrs Creagan’s heart failure during her inpatient treatment.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to diagnose infective endocarditis
Wider context from the report “1. BHRUT chose not to investigate this case as part of NHS England’s Patient Safety Framework. Mrs Creagan’s death ought to have been subject to such an investigation.
Decisions were reached at two clinical governance meetings that meaningful learning could not flow from a governance investigation into the circumstances of Mrs Creagan’s care. Such decisions appear to be incongruous with;
a. The inaccurate cause of death initially offered by the Trust,
b. The failure to investigate the seat of Mrs Creagan’s burgeoning infection after her pneumonia resolved.
c. The missed diagnosis of infective endocarditis ,
d. The failure to monitor the development of Mrs Creagan’s heart failure during her inpatient treatment.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor developing heart failure during inpatient treatment
Wider context from the report “1. BHRUT chose not to investigate this case as part of NHS England’s Patient Safety Framework. Mrs Creagan’s death ought to have been subject to such an investigation.
Decisions were reached at two clinical governance meetings that meaningful learning could not flow from a governance investigation into the circumstances of Mrs Creagan’s care. Such decisions appear to be incongruous with;
a. The inaccurate cause of death initially offered by the Trust,
b. The failure to investigate the seat of Mrs Creagan’s burgeoning infection after her pneumonia resolved.
c. The missed diagnosis of infective endocarditis,
d. The failure to monitor the development of Mrs Creagan’s heart failure during her inpatient treatment .
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate the source of a progressing infection after pneumonia resolves
Wider context from the report “1. BHRUT chose not to investigate this case as part of NHS England’s Patient Safety Framework. Mrs Creagan’s death ought to have been subject to such an investigation.
Decisions were reached at two clinical governance meetings that meaningful learning could not flow from a governance investigation into the circumstances of Mrs Creagan’s care. Such decisions appear to be incongruous with;
a. The inaccurate cause of death initially offered by the Trust,
b. The failure to investigate the seat of Mrs Creagan’s burgeoning infection after her pneumonia resolved .
c. The missed diagnosis of infective endocarditis,
d. The failure to monitor the development of Mrs Creagan’s heart failure during her inpatient treatment.
” 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 Require multidisciplinary clinical review of relevant coronial cases, including cases involving concerns about diagnosis, deterioration, monitoring, treatment or missed opportunities.
Verbatim wording from the response “The Trust has reflected carefully on the concern expressed in the Report that meaningful learning should have flowed from the circumstances of Mrs Creegan’s care. We accept the need to demonstrate clearly, in coronial cases, that learning is being actively pursued and is not dependent on PSIRF alone. Our revised approach is that coronial cases of this nature will be considered through the CCRM and, where relevant, alongside other existing review methodologies so that there is explicit multidisciplinary scrutiny, clear senior clinical oversight, and a documented record of the Trust’s appraisal of the care and the resulting actions.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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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 Operate the Coroner’s Case Review Meeting as a formal governance mechanism for multidisciplinary oversight of inquest and coronial cases.
Verbatim wording from the response “To have good governance process to support these decisions, HM Coroner will be aware that the Trust has now established a Coroner’s Case Review Meeting (CCRM) as part of its formal coronial governance arrangements.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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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 Clarify in governance arrangements that PSIRF is one learning mechanism and not the Trust’s sole route for reviewing deaths or responding to coronial concerns.
Verbatim wording from the response “• Clarification within governance arrangements that PSIRF is one mechanism for learning, but not the sole route by which the Trust reviews deaths, identifies learning, or responds to coronial concerns.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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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 Use multiple review routes, including MDT, mortality, complaints, clinician reflection and CCRM reviews, rather than relying solely on PSIRF.
Verbatim wording from the response “The Trust agrees that learning should not be constrained by whether a case meets a particular PSIRF learning response threshold. In these cases, a number of review methods have been, and continue to be, used to examine the care provided and identify learning. These include:” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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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 Existing clinical reviews, mortality review, governance meetings and reflection had identified sufficient learning, so a PSII would not add further learning.
Verbatim wording from the response “The group was asked to reflect specifically on whether declaring a Patient Safety Incident Investigation (PSII) would have generated additional learning beyond what had already been obtained. A full clinical timeline had already been completed; a Trust Mortality review and the case had been discussed at Trust wide meetings with senior medical representation. Reflective learning was also presented by the Quality and Safety Team to seek clinical colleagues’ views on whether the incident had been managed appropriately by the Quality and Safety Advisor with a focus on ensuring optimal care and outcomes for patients going forward.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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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 The initial cause of death reflected the best clinical judgment based on information available during life, not a failure in care or decision-making.
Verbatim wording from the response “At the time of death certification and Medical Examiner (ME) scrutiny, there was no clinical evidence during life to suggest bacterial endocarditis. Mrs Creegan had been diagnosed with hospital acquired pneumonia and decompensated heart failure, both of which were supported by contemporaneous clinical findings, blood results, radiological imaging, and physical examination.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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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 Heart failure was actively monitored and treated, and no contemporaneous indicators mandated a repeat echocardiogram.
Verbatim wording from the response “The decision not to repeat an echocardiogram during this admission was considered reasonable in context. Mrs Creegan had undergone an ECHO in October 2024 demonstrating preserved left ventricular function (EF 55–60%), and her subsequent clinical deterioration was attributed to fluid overload and infection, both of which were actively managed.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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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 Further invasive or extensive investigation was not considered clinically appropriate because it was unlikely to alter management or improve outcomes.
Verbatim wording from the response “A multidisciplinary review involving the Consultant Geriatrician workforce concluded that further invasive or extensive investigations were unlikely to alter management or improve outcomes and were therefore not clinically appropriate. This decision was made in line with best interest principles and realistic treatment goals.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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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 There were no clinical indicators during life that would reasonably have prompted investigation or diagnosis of bacterial endocarditis.
Verbatim wording from the response “The postmortem diagnosis of bacterial endocarditis was unexpected. During life, Mrs. Creegan did not display classical features that would have prompted suspicion, such as persistent bacteraemia, new cardiac murmurs, embolic phenomena, or a deteriorating cardiac picture unexplained by existing conditions.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
Open published response
14 Oct 2025 Mohan Singh Hothi · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Failure to identify, reflect upon, and remediate sub-optimal practice View source Failure to provide complete evidence of reflection and remediation View source Failure to assess serious unwitnessed falls for investigation through the Patient Safety Framework View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mohan Singh Hothi · 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
Mohan Singh Hothi was admitted to hospital after a fall at home and was found to have a catastrophic subdural haematoma; he died later that day. Concerns included the Trust not investigating two serious injuries from previous unwitnessed falls through its Patient Safety Framework, and vague and incomplete evidence about reflection and remediation.
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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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify, reflect upon, and remediate sub-optimal practice
Wider context from the report “1. Mohan Singh Hothi died in hospital on 28th March 2025 due to injuries sustained in a fall at home in the early hours of the morning. During a previous hospital admission beginning in February 2025 and concluding on 20th March 2025 Mr Hothi sustained injuries in two separate unwitnessed falls, these injuries were serious (one requiring surgery) but could not be said to have contributed to his death. The two separate incidents were not assessed by the Trust as 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 .
2. Evidence provided by the Trust at inquest to identify that reflection and remediation had been undertaken was vague and incomplete
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide complete evidence of reflection and remediation
Wider context from the report “1. Mohan Singh Hothi died in hospital on 28th March 2025 due to injuries sustained in a fall at home in the early hours of the morning. During a previous hospital admission beginning in February 2025 and concluding on 20th March 2025 Mr Hothi sustained injuries in two separate unwitnessed falls, these injuries were serious (one requiring surgery) but could not be said to have contributed to his death. The two separate incidents were not assessed by the Trust as 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.
2. Evidence provided by the Trust at inquest to identify that reflection and remediation had been undertaken was vague and incomplete
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess serious unwitnessed falls for investigation through the Patient Safety Framework
Wider context from the report “1. Mohan Singh Hothi died in hospital on 28th March 2025 due to injuries sustained in a fall at home in the early hours of the morning. During a previous hospital admission beginning in February 2025 and concluding on 20th March 2025 Mr Hothi sustained injuries in two separate unwitnessed falls, these injuries were serious (one requiring surgery) but could not be said to have contributed to his death. The two separate incidents were not assessed by the Trust as 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.
2. Evidence provided by the Trust at inquest to identify that reflection and remediation had been undertaken was vague and incomplete
” 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 Review the post-fall action plan with nursing teams after every reported fall to ensure appropriate assessments and maintain patient safety.
Verbatim wording from the response “In February 2025, a total of 36 falls were reported, increasing to 45 falls in March 2025, compared with an average of approximately 25 falls per month in the Geriatrics Care Group. In response to this rise in falls and the associated risk of serious patient harm, the Head of Nursing and The Quality and Safety Advisor in Geriatrics implemented an action plan to address and monitor the situation. This action plan included the following measures:” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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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 Report all Geriatrics Care Group inpatient falls, including serious-harm incidents, to the Quality Governance and Steering Group and record escalation decisions for Trust Board reporting.
Verbatim wording from the response “4. All inpatient falls within the Geriatrics Care Group are reported to the Trust’s Quality Governance and Steering Group (QGSG), with any falls resulting in serious harm detailed. Decisions regarding escalation for a learning response are formally recorded and reported to the Trust Board.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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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 Commence covert observational audits across Geriatrics wards and departments to measure nursing response times to patient call bells and identify delays requiring further action.
Verbatim wording from the response “Further action to be completed” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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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 Discuss every reported fall at weekly Geriatrics Care Group incident reviews, share learning, and assess whether escalation for a wider learning response is required.
Verbatim wording from the response “2. Every reported fall incident is discussed at the weekly Geriatrics Care Group incident review meeting, chaired by the Quality and Safety Advisor, to determine preventability, assess any harm sustained and share learning across the Care Group.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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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 Provide continuing Falls Lead communication and support to identify training needs and implement resulting training across the Geriatrics Care Group.
Verbatim wording from the response “5. Ongoing communication and support from the Trust Falls Lead is provided to identify training needs which are subsequently implemented across the Care Group.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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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 Because the contributing factors were known and understood, no further investigation or learning response was considered necessary.
Verbatim wording from the response “In accordance with the Patient Safety Incident Review Framework (PSIRF) and the Trust PSIRF plan, incidents are referred for a learning response when the contributing factors are not well understood or when there is potential for significant local or organisational learning. Following the review of incidents ████████, it was determined that the underlying factors were clearly understood – specifically that Mr Hothi chose to mobilise independently without awaiting assistance from nursing staff.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The inpatient falls were considered unpreventable, disputing that further investigation would identify preventable sub-optimal practice.
Verbatim wording from the response “The investigations conducted under incident reference numbers ████████ concluded that both falls were unpreventable. Mr Hothi was assessed as having full mental capacity, displayed no signs of confusion, and was able to understand and follow instructions. Under these circumstances, patients are not provided with constant supervision, as they are deemed capable of communicating their care needs to the nursing staff. Moreover, continuous supervision would require the implementation of a Deprivation of Liberty Safeguards (DoLS) authorisation, for which Mr Hothi did not meet the criteria.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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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 Existing actions to manage the understood fall risk factors were considered sufficient, so no further investigation was required.
Verbatim wording from the response “• The factors contributing to Mr Hothi’s falls were known and understood; therefore, no further investigation was required. Ongoing actions to manage these factors were already in place.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
Open published response
9 Oct 2025 Matthew Goldsmith · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Failure to report abnormal abdominal vascular findings on CT scans View source Lack of peer review of reported radiology cases View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Matthew Goldsmith · 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
Matthew Goldsmith died on 29 October 2024 after an occluded superior mesenteric artery caused bowel ischaemia and perforation. Relevant vascular abnormalities were missed on multiple CT scans, including severe stenosis or occlusion of the superior mesenteric artery. The report also identified concern that the Trust did not have the required radiology peer review process in place.
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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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to report abnormal abdominal vascular findings on CT scans
Wider context from the report “Abnormal findings in the abdominal vascular system were apparent on 3 CT scans from January 2020 to October 2024 but not reported by the reviewing radiologists.
In January 2020 a CT trauma scan was carried out following a road traffic collision. This scan showed an occluded right common iliac artery and origin of inferior mesenteric artery. Whilst these findings were not relevant to the clinical condition at the time, they should have been reported.
In April 2024 the CT scan of the chest showed occlusion of the infrarenal aorta, bilateral common iliac artery and right external iliac artery. There was severe stenosis of the superior mesenteric artery in its mid segment. The latter finding was of direct clinical interest. None of these findings were reported.
On 10 October 2024 an abdominal CT scan showed occlusion of the superior mesenteric artery mid segment. This was directly relevant to the clinical condition and it was not reported.
The Royal College of Radiologists Guidance requires peer review of 5-10% of reported radiology cases as part of a Trust’s quality assurance process. At the date of the inquest, Barking Havering & Redbridge NHS Trust does not have such a peer review system in place.
In light of the number of missed radiological findings in this case, by 3 separate radiologists, it is of concern that the peer review process is not taking place at the trust.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of peer review of reported radiology cases
Wider context from the report “Abnormal findings in the abdominal vascular system were apparent on 3 CT scans from January 2020 to October 2024 but not reported by the reviewing radiologists.
In January 2020 a CT trauma scan was carried out following a road traffic collision. This scan showed an occluded right common iliac artery and origin of inferior mesenteric artery. Whilst these findings were not relevant to the clinical condition at the time, they should have been reported.
In April 2024 the CT scan of the chest showed occlusion of the infrarenal aorta, bilateral common iliac artery and right external iliac artery. There was severe stenosis of the superior mesenteric artery in its mid segment. The latter finding was of direct clinical interest. None of these findings were reported.
On 10 October 2024 an abdominal CT scan showed occlusion of the superior mesenteric artery mid segment. This was directly relevant to the clinical condition and it was not reported.
The Royal College of Radiologists Guidance requires peer review of 5-10% of reported radiology cases as part of a Trust’s quality assurance process. At the date of the inquest, Barking Havering & Redbridge NHS Trust does not have such a peer review system in place.
In light of the number of missed radiological findings in this case, by 3 separate radiologists, it is of concern that the peer review process is not taking place at the trust.
” 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 Conduct plain-film peer reviews at the established five-percent level using the Radiology specialty lead and shared governance records.
Verbatim wording from the response “Plain Film Peer Review
Within Radiology, the plain film x-ray specialty has already commenced peer reviews which has been in place for over 12 months and from July 2025, the specialty has managed to peer review 5% of cases and is being led by the Radiology Specialty lead. A Standard operating procedure was created and will be replicated to the other modality/specialty areas. A shared governance file stores all reviewed cases.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce Radiology peer review aligned with RCR guidance, scaling monthly case reviews and reporting learning through governance dashboards.
Verbatim wording from the response “• Development and implementation of a peer review process for Radiology in alignment with RCR guidance, ensuring systematic case review and feedback mechanisms.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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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 Deliver a grand round teaching session on acute and chronic presentations of mesenteric arterial occlusion.
Verbatim wording from the response “1. A grand round teaching session will be delivered on 11 December 2025 by the Surgical Clinical Group around acute and chronic presentation of mesenteric arterial occlusion. The Grand round is a regular learning session led by the Director of Medical Education to review incidents where learning has been established. At this grand round colleagues from the upper Gastrointestinal and Vascular teams were present.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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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 Replicate the plain-film peer-review standard operating procedure across other Radiology modalities and specialties.
Verbatim wording from the response “Plain Film Peer Review
Within Radiology, the plain film x-ray specialty has already commenced peer reviews which has been in place for over 12 months and from July 2025, the specialty has managed to peer review 5% of cases and is being led by the Radiology Specialty lead. A Standard operating procedure was created and will be replicated to the other modality/specialty areas. A shared governance file stores all reviewed cases.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
Open published response
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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 Introduce a SEIPS-based discrepancy-learning project, including rapid reviews and dual-track PSIRF systems-thinking investigations.
Verbatim wording from the response “• Introduction of a SEIPS-based project to identify and address human and system factors contributing to reporting discrepancies.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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25 Oct 2024 Chloe Every · Prevention of Future Deaths report East London
View report summary
Concerns raised 8 Failure of Serious Incident investigations to identify healthcare failings View source Lack of nursing staff knowledge of criteria for commencing CPR on an unresponsive patient View source Lack of nursing cover during weekends and holiday periods by staff with relevant learning disability training View source Failure to maintain contemporary nursing and medical records of treatment and treatment decisions View source Delays in reporting deaths to a Coroner View source Failure to obtain informed consent before undertaking an enema View source Failure to undertake clinical observations at the expected frequency View source Failure of governance processes to identify patient safety incidents through mortality review View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Chloe Every · 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
Chloe Every died in hospital on 14 May 2019 after complications from a hypoxic cardiac arrest sustained during her admission. The report identified concerns including morphine use without recorded justification, an enema undertaken without informed consent while she was unconscious, inadequate clinical observations, missing records, and failures in incident reporting and governance.
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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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Serious Incident investigations to identify healthcare failings
Wider context from the report “7. A Serious Incident report completed by the trust in the second half of 2019 failed to identify a series of healthcare failings in Chloe’s treatment. Management failings at the Trust meant that Chloe’s death was not reported to a Coroner until August 2023, by which time Chloe’s body had been cremated denying the court an opportunity to gather relevant evidence through autopsy.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of nursing staff knowledge of criteria for commencing CPR on an unresponsive patient
Wider context from the report “5. Nursing staff were incapable of explaining to the court the appropriate criteria that would have to exist before commencing CPR on an unresponsive patient.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of nursing cover during weekends and holiday periods by staff with relevant learning disability training
Wider context from the report “1. The Trust does not provide nursing cover during weekends and holiday periods of staff with relevant learning disability training.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain contemporary nursing and medical records of treatment and treatment decisions
Wider context from the report “2. The investigation of this inquest was prejudiced by the absence of contemporary nursing and medical notes from various stages of Chloe's treatment . The extent of these lapses meant staff who made important treatment decisions could not be identified, and where staff could be identified, no contemporary account of their rationale for making treatment decisions could be located .
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in reporting deaths to a Coroner
Wider context from the report “7. A Serious Incident report completed by the trust in the second half of 2019 failed to identify a series of healthcare failings in Chloe’s treatment. Management failings at the Trust meant that Chloe’s death was not reported to a Coroner until August 2023 , by which time Chloe’s body had been cremated denying the court an opportunity to gather relevant evidence through autopsy.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain informed consent before undertaking an enema
Wider context from the report “4. Chloe underwent an enema on 8th May 2019 without informed consent being taken . The court found that Chloe was unconscious, before, during, and after the procedure, it is possible this procedure contributed to her death.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake clinical observations at the expected frequency
Wider context from the report “3. The regularity of Chloe’s clinical observations fell well below the expected level. The lapses included a period of over 10 hours in which no observations were undertaken .
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of governance processes to identify patient safety incidents through mortality review
Wider context from the report “6. Governance processes at the Trust failed to identify that Chloe’s death constituted a patient safety incident until months after her death. A mortality review authored by the Associated Medical Director on 17th May 2019 assessed Chloe’s care as good or excellent.
” Open source report
×
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 Complete review and approval of an Easy Read consent-information leaflet for patients with Learning Disabilities.
Verbatim wording from the response “An Easy Read leaflet on Information about Consent for patients with Learning Disabilities has been drafted and is currently going through review and approval processes with expected completion in February 2025.” Source location Response from Barking, Havering and Redbridge NHS Foundation Trust
Open published response
×
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 Recruit additional Learning Disability-qualified nurses for acute wards and emergency departments.
Verbatim wording from the response “There are ongoing plans to employ more nurses with Learning Disabilities qualifications in the Trust which will include the acute ward and emergency department (ED) areas; the recruitment process is underway. The nurses will work in the clinical areas as part of the workforce and will be allocated to care for patients with Learning Disabilities within their area.” Source location Response from Barking, Havering and Redbridge NHS Foundation Trust
Open published response
×
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 Provide live observation-frequency dashboards and monthly compliance reports to senior clinical staff.
Verbatim wording from the response “There is live data in the format of a dashboard showing compliance with expected observation frequency available to senior staff within clinical areas (ward managers, matrons, practice development nurses and clinical group directors). Additional monthly performance reports have been sent to the same staffing groups since December 2023. Vital signs recording and actions form part of the Ward Accreditation Framework process and clinical areas work with the VitalPac team to continue to improve the timings of observations.” Source location Response from Barking, Havering and Redbridge NHS Foundation Trust
Open published response
×
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 Operate the Learning Review Group to oversee learning responses, PSIRF adherence and development of improvement actions.
Verbatim wording from the response “In July 2024, the Learning Review Group was established. The Learning Review Group undertakes an oversight function to assess the quality of learning responses and adherence with PSIRF methodology. This multi-professional group ensures an appropriate systems-based approach has been used to extract learning from learning responses and develop robust improvement actions, as well as ensuring that compassionate engagement with patients, families and staff has been central to the learning response.” Source location Response from Barking, Havering and Redbridge NHS Foundation Trust
Open published response
×
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 Monitor safety actions and improvement plans through the Improvement Oversight Panel, including scheduled three-month progression reviews.
Verbatim wording from the response “The Trust is monitoring implementation of the safety actions arising from learning responses via the Improvement Oversight Panel (IOP) which was implemented in July 2024. This panel oversees the effectiveness of safety actions and wider safety improvement plans to ensure they are delivering the required improvement. The panel will consider whether sufficient evidence is available of sustainable improvement, prior to closure of the relevant patient safety incidents, or where it is absent, consider what further improvement actions are needed.” Source location Response from Barking, Havering and Redbridge NHS Foundation Trust
Open published response
×
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 Establish and operate a Quarterly Health Records Group to review best practice, learning opportunities and resulting action plans.
Verbatim wording from the response “In August 2024, the Medical Directorate established a Quarterly Health Records Group where both best practice and learning opportunities will be presented and reviewed with action plans as appropriate.” Source location Response from Barking, Havering and Redbridge NHS Foundation Trust
Open published response
×
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 Update the Consent to Examination and Treatment policy with guidance on implied consent.
Verbatim wording from the response “The Trust’s Consent to Examination and Treatment policy section 4.1.4 'Procedures to follow when patients lack capacity to give or withhold consent' includes guidance on when and how to apply. The policy will be updated by February 2025 to include guidance on implied consent.” Source location Response from Barking, Havering and Redbridge NHS Foundation Trust
Open published response
×
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 Implement a full Electronic Patient Care Record to integrate clinical records.
Verbatim wording from the response “The Trust currently remains on part electronic and paper records. However, there has been significant progress towards a more integrated system. The Trust is in the planning stages of implementation of a full Electronic Patient Care Record (EPR) with the planned date for implementation of June 2025. Implementation is supported by a team of clinical and digital staff, with progress monitored through the Trust Executive Committee and the Trust Board.” Source location Response from Barking, Havering and Redbridge NHS Foundation Trust
Open published response
×
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 Deliver informed-consent training covering Montgomery law and GMC and NMC requirements.
Verbatim wording from the response “The Legal team will deliver training about informed consent including Montgomery Law and GMC and NMC requirements in January 2025.” Source location Response from Barking, Havering and Redbridge NHS Foundation Trust
Open published response
×
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 Review all deaths through the Medical Examiner Office, including cause-of-death certification, bereaved-family concerns and referrals for further review.
Verbatim wording from the response “Since September 2024 all deaths have been reviewed by the Medical Examiner Office. The role of these offices is to examine deaths to:” Source location Response from Barking, Havering and Redbridge NHS Foundation Trust
Open published response
×
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 Operate the Resuscitation Service to review cardiac and emergency calls, mandate incident reporting and support teaching and deteriorating-patient review.
Verbatim wording from the response “The Trust commissioned, from external experts, a review of the Resuscitation Services provided by the Trust. As a result of the review, the Trust’s Resuscitation Services was established in March 2022. The service reviews all Cardiac and Emergency calls and mandates the reporting of all calls on the incident reporting system. The service comprises a team of 6 members of staff who are able to support both the teaching and review of deteriorating patients.” Source location Response from Barking, Havering and Redbridge NHS Foundation Trust
Open published response
×
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 Deliver Good Medical Record Keeping training through Legal Services and junior doctors’ emergency department induction.
Verbatim wording from the response “As a practical response to this concern, the Trust’s Legal Services Department now routinely deliver training sessions on “The importance of Good Record Keeping”. The training puts particular focus on the importance of good medical documentation being a fundamental aspect of clinicians’ duty in providing patient care; ensuring patient’s needs are met; ensuring continuity of care; ensuring effective evidence of the standard of care and decision-making process.” Source location Response from Barking, Havering and Redbridge NHS Foundation Trust
Open published response
×
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 Conduct ward accreditation, deteriorating-patient audits and NEWS escalation audits to monitor observation and escalation compliance.
Verbatim wording from the response “The wards areas in the Trust are subject to assessment utilising the Ward Accreditation Framework (WAF) which monitors metrics related to patient care and safety, as well as how the wards are operated. Audits are completed annually by subject matter experts and any areas in which the ward falls below 70% compliance is addressed with an action plan. The WAF framework assesses the nursing staff knowledge of the escalation process for deteriorating patients. The Ward Accreditation assessments started in 2020 and since then all wards in the Trust have completed and have achieved a minimum of a bronze standard for ward accreditation with many at Silver and working towards gold.” Source location Response from Barking, Havering and Redbridge NHS Foundation Trust
Open published response
×
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 Undertake paper-based CRABEL medical-record audits across specialties and share results Trust-wide.
Verbatim wording from the response “The Trust lead for mortality and Caldicott Guardian is in the process of organising CRABEL audits (an audit tool designed by Crawford – Bresford – Lafferty) as a tool for the assessment of the quality of medical record keeping, with the ability to standardise audit and improvement across areas. A paper-based CRABEL audit is being undertaken within different specialties and results will be shared trust wide.” Source location Response from Barking, Havering and Redbridge NHS Foundation Trust
Open published response
×
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 The Trust cannot provide continuous learning disability nursing cover because suitably qualified nurses are unavailable and not recruitable.
Verbatim wording from the response “It was submitted in evidence at the hearing that the Trust has made efforts to recruit qualified Learning Disability nurses to provide cover during weekends and holiday periods. The absence of nursing cover at these times is not a matter of a lack of resource, but an issue with having a cohort of available, recruitable nurses with this specific qualification. Our review identified that no acute Trust in London has Learning Disability nurses on a 24/7 basis.” Source location Response from Barking, Havering and Redbridge NHS Foundation Trust
Open published response
19 Sep 2024 Gordon Long · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Inadequate patient safety incident investigations View source Failure to demonstrate change following agreed care-remediation actions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Gordon Long · 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
Gordon Long was admitted to hospital on 1 July 2023 with suspected dry gangrene of the left foot, was assessed by a vascular specialist on 6 July, underwent amputation on 7 July, and died on 8 July 2023. The concerns were the unexplained delay in referral to the vascular team, shortcomings in the patient safety investigation, and the lack of clear evidence that an action plan had resulted in changed practice.
Read the report on judiciary.uk
× 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate patient safety incident investigations
Wider context from the report “1. Despite undertaking a patient safety incident investigation (“PSII”) the Trust was unable to explain why Mr Long was not referred to the vascular team after he was admitted from ED into the medical receiving unit (“MRU”) on the morning of 2nd July 2023. The Trust struggled to identify the consultant in charge of Mr Long’s treatment when on the MRU and could not demonstrate that the consultant was spoken to as part of the PSII investigation . The inadequate standard of the investigation makes the court doubt the effectiveness of the Trust to identify and reflect upon future risks to patients.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to demonstrate change following agreed care-remediation actions
Wider context from the report “2. Although an action plan had been agreed by the Trust to remediate the failures in care that led to the delayed referral, no clear evidence of change was demonstrated to the court .
” Open source report
4 Jul 2024 David John Morris · Prevention of Future Deaths report East London
View report summary
Concerns raised 9 Poor communication in cancer diagnosis and treatment View source Failure of serious incident investigations to identify relevant reviewing clinicians View source Failure to treat and escalate suspected sepsis promptly View source Poor organisation of cancer diagnosis and treatment View source Ineffective controlled drug management systems for detecting prolonged theft and self-administration View source Failure to effectively review how deficient investigation reports gain executive approval View source Poor or absent clinical records View source Failure to identify the extent of gastrostomy leaks and onset of sepsis View source Unfit serious incident investigation reports View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David John Morris · 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
David John Morris, aged 78, developed oesophageal cancer after delays in diagnosis and treatment, later undergoing gastrostomy surgery. He developed a gastrostomy leak, peritonitis and septic shock, and died in hospital on 16 May 2022 after further surgery. The concerns included delayed recognition and treatment of the leak and sepsis, poor clinical records, deficiencies in the investigation, and ineffective controlled-drug management systems.
Read the report on judiciary.uk
× 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Poor communication in cancer diagnosis and treatment
Wider context from the report “1. Mr Morris’s diagnosis and treatment for cancer was delayed due to poor organisation and communication at the Trust .
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of serious incident investigations to identify relevant reviewing clinicians
Wider context from the report “4. The initial serious investigation report into Mr Morris’s death was unfit for purpose. The report to investigate or even identify the Registrar who reviewed Mr Morris on the evening of 3rd May 2022 . Since then, no effective review has been undertaken by the Trust upon how this deficient report gained executive approval.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to treat and escalate suspected sepsis promptly
Wider context from the report “2. During the evening of 3rd May 2022 going into the early hours of 4th May 2022, Doctors and nurses failed to identify the extent of Mr Morris’s gastrostomy leak and the onset of sepsis. After identifying symptoms of sepsis, staff failed to treat and escalate Mr Morris’s case resulting in a delay of three and a half hours before a medical review commenced emergency treatment .
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Poor organisation of cancer diagnosis and treatment
Wider context from the report “1. Mr Morris’s diagnosis and treatment for cancer was delayed due to poor organisation and communication at the Trust.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffective controlled drug management systems for detecting prolonged theft and self-administration
Wider context from the report “5. The Trust did not have effective controlled drug management systems in place to detect a prolonged and persistent course of conduct from an employed nurse who was stealing and self- administering controlled drugs in the workplace .
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to effectively review how deficient investigation reports gain executive approval
Wider context from the report “4. The initial serious investigation report into Mr Morris’s death was unfit for purpose. The report to investigate or even identify the Registrar who reviewed Mr Morris on the evening of 3rd May 2022. Since then, no effective review has been undertaken by the Trust upon how this deficient report gained executive approval .
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Poor or absent clinical records
Wider context from the report “3. During Mr Morris’s ward-based treatment on 3 & 4th May 2022 clinical records were either of a poor standard or were non-existent . The absence of clear records impeded the effective investigation of this death by the Trust’s governance teams and the Coroner.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify the extent of gastrostomy leaks and onset of sepsis
Wider context from the report “2. During the evening of 3rd May 2022 going into the early hours of 4th May 2022, Doctors and nurses failed to identify the extent of Mr Morris’s gastrostomy leak and the onset of sepsis . After identifying symptoms of sepsis, staff failed to treat and escalate Mr Morris’s case resulting in a delay of three and a half hours before a medical review commenced emergency treatment.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unfit serious incident investigation reports
Wider context from the report “4. The initial serious investigation report into Mr Morris’s death was unfit for purpose . The report to investigate or even identify the Registrar who reviewed Mr Morris on the evening of 3rd May 2022. Since then, no effective review has been undertaken by the Trust upon how this deficient report gained executive approval.
” 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 Require Learning Review Group sign-off with Board Executive attendance for quoracy when approving patient safety investigations.
Verbatim wording from the response “On completion of Patient Safety Incident Investigations (PSIIs) there is a Learning Review Group (LRG) which reviews the contents of the reports to ensure adequate exploration of key issues has occurred and that the family has had an opportunity to input into the investigation; and ensures the improvement action plan both aligns with learning identified and is sufficiently robust to counteract the existing safety issues identified. The Terms of Reference for this meeting have been updated and now include a Board Executive (or nominated deputy) who must be in attendance for quoracy when signing off investigations.” Source location 2024-0360 - Response from Barking Havering and Redbridge NHS Trust
Open published response
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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 Develop online training for recognising deteriorating patients.
Verbatim wording from the response “Finally, there is now a deteriorating patient panel group which meets weekly and reviews patients that have had a deterioration in clinical condition and uses this information/learning to change practice both locally and Trust-wide. To assist in the familiarity of the process and policy for deteriorating patients, this is now included in Basic Life Support training which is an essential requirement for all clinical staff. There is also a development of an online training for the recognition of deteriorating patients.” Source location 2024-0360 - Response from Barking Havering and Redbridge NHS Trust
Open published response
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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 Explore installing CCTV in medicine preparation rooms.
Verbatim wording from the response “In light of the concerns raised by the learned Coroner, the Trust is trialing a digital key system on each ward, together with exploring installing CCTV into the Medicine Preparation rooms. An initial discussion with suppliers took place in July 2024.” Source location 2024-0360 - Response from Barking Havering and Redbridge NHS Trust
Open published response
×
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 Operate a weekly deteriorating patient panel to review deterioration and use learning to change practice.
Verbatim wording from the response “Finally, there is now a deteriorating patient panel group which meets weekly and reviews patients that have had a deterioration in clinical condition and uses this information/learning to change practice both locally and Trust-wide. To assist in the familiarity of the process and policy for deteriorating patients, this is now included in Basic Life Support training which is an essential requirement for all clinical staff. There is also a development of an online training for the recognition of deteriorating patients.” Source location 2024-0360 - Response from Barking Havering and Redbridge NHS Trust
Open published response
×
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 Introduce a Medicine Management Nurse role to support compliance with medication policies.
Verbatim wording from the response “To assist with compliance with the medication policies, a Medicine Management Nurse is being introduced within the Trust and the recruitment process is currently underway. Advertising of the post should begin in October 2024 with appointment following this.” Source location 2024-0360 - Response from Barking Havering and Redbridge NHS Trust
Open published response
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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 Trial a digital key system on each ward for controlled medication management.
Verbatim wording from the response “In light of the concerns raised by the learned Coroner, the Trust is trialing a digital key system on each ward, together with exploring installing CCTV into the Medicine Preparation rooms. An initial discussion with suppliers took place in July 2024.” Source location 2024-0360 - Response from Barking Havering and Redbridge NHS Trust
Open published response
×
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 Operate a weekly Incident Oversight Learning Group to review concerning incidents and commission further learning responses where needed.
Verbatim wording from the response “There is a weekly Incident Oversight Learning Group (IOLG) whereby all incidents that are considered of concern are discussed with specific terms of reference. This includes background information and a review of the entire pathway which a patient has encountered when systems issues are identified; thereby including any omissions that may have occurred with the previous Serious Incident Framework. The Incident Oversight Learning Group meetings are chaired by either the Medical Director for Patient Safety and Patient Experience or the Director of Nursing for Quality and Safety, and this group decides when to commission a further PSIRF learning response.” Source location 2024-0360 - Response from Barking Havering and Redbridge NHS Trust
Open published response
×
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 Use the Patient Safety Investigation Response Framework with multidisciplinary investigations and centrally allocated investigating officers.
Verbatim wording from the response “Since October 2023 there has been a change in the process of investigating significant patient safety incidents at BHRUT. This has now been changed to the Patient Safety Investigation Response Framework (PSIRF) which uses multidisciplinary investigations and reviews with multiple responsible authors. In line with NHS England guidance, the Investigating Officer is centrally allocated by the Quality and Safety team and, whenever possible, these are allocated outside of the Clinical Group where the incident occurred.” Source location 2024-0360 - Response from Barking Havering and Redbridge NHS Trust
Open published response
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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 Require responsible consultant approval before removing or deferring any cancer patient from the Patient Tracker List.
Verbatim wording from the response “Mr Morris’s treatment plan and diagnosis was delayed and complicated in part due to being downgraded in severity on the Patient Tracker List which led to a breakdown in communication between clinical pathways. With immediate effect, no patients that are currently on a Patient Tracker List for any cancer diagnosis can be removed or deferred without approval of the responsible consultant. This is to ensure that administrative processes have a clear oversight of a senior clinician who takes full responsibility for the treatment plan.” Source location 2024-0360 - Response from Barking Havering and Redbridge NHS Trust
Open published response
×
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 Provide a dedicated 24-hour, seven-day Critical Care Outreach Team service.
Verbatim wording from the response “The Trust has implemented an increase in our Critical Care Outreach Team (CCOT) model since April 2024. Previously this service was offered between the hours of 8am to 8pm with no dedicated service outside of these hours. Since April 2024 this is now a dedicated twenty-four-hour service delivered seven days a week to ensure continuity and access to specialised teams as required.” Source location 2024-0360 - Response from Barking Havering and Redbridge NHS Trust
Open published response
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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 Restructure cancer administration pathways to provide new clinical oversight and streamlined communication.
Verbatim wording from the response “In addition, a restructure of the cancer administration pathways is underway by the Speciality Manager for cancer performance; under the oversight of the Chief Operating Officer. This restructure is proposed to finish by 30 September 2024, with its implementation expected to result in new clinical oversight and streamlined communication.” Source location 2024-0360 - Response from Barking Havering and Redbridge NHS Trust
Open published response
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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 Make contemporaneous, clear clinical documentation a mandatory part of medical and nursing induction for new starters.
Verbatim wording from the response “The standard of documentation was highlighted as being of a poor quality. The Trust is in the process of preparing for the introduction of an Electronic Patient Records (EPR) system, which is due to be adopted in May 2025. Adopting the EPR system will involve a process where contemporaneous and clear clinical documentation is made during clinical episodes of care; and this practice will be highlighted as a mandatory part of the medical and nursing induction process for all new starters.” Source location 2024-0360 - Response from Barking Havering and Redbridge NHS Trust
Open published response
×
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 Design and implement Martha’s Rule, enabling patients, relatives and staff to request rapid Critical Care Outreach Team review.
Verbatim wording from the response “Additionally, the Trust is currently in the process of designing and implementing Martha’s Rule, which is based upon the case of Martha Mills who died in 2021 after developing sepsis in hospital. In response to hers and other cases related to the management of deterioration, the Secretary of State for Health and Social Care and NHS England committed to implementing ‘Martha’s Rule’; to ensure the vitally important concerns of the patient and those who know the patient best are listened to and acted upon.” Source location 2024-0360 - Response from Barking Havering and Redbridge NHS Trust
Open published response
×
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 Review the feasibility of CRABEL audits and prepare a plan for approval to assess medical record-keeping quality.
Verbatim wording from the response “In addition, the Trust lead for mortality is reviewing the possibility of performing CRABEL audits (an audit tool designed by CRawford – BEresford – LAfferty) as a tool for the assessment of the quality of medical record keeping, with the ability to standardise audit and improvement across areas. A plan is due to be presented for approval in November 2024 following the second meeting of the Health Records Group.” Source location 2024-0360 - Response from Barking Havering and Redbridge NHS Trust
Open published response
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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 Include deteriorating-patient processes and policy in mandatory Basic Life Support training for clinical staff.
Verbatim wording from the response “Finally, there is now a deteriorating patient panel group which meets weekly and reviews patients that have had a deterioration in clinical condition and uses this information/learning to change practice both locally and Trust-wide. To assist in the familiarity of the process and policy for deteriorating patients, this is now included in Basic Life Support training which is an essential requirement for all clinical staff. There is also a development of an online training for the recognition of deteriorating patients.” Source location 2024-0360 - Response from Barking Havering and Redbridge NHS Trust
Open published response
×
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 Prepare for adoption of an Electronic Patient Records system supporting contemporaneous, clear clinical documentation.
Verbatim wording from the response “The standard of documentation was highlighted as being of a poor quality. The Trust is in the process of preparing for the introduction of an Electronic Patient Records (EPR) system, which is due to be adopted in May 2025. Adopting the EPR system will involve a process where contemporaneous and clear clinical documentation is made during clinical episodes of care; and this practice will be highlighted as a mandatory part of the medical and nursing induction process for all new starters.” Source location 2024-0360 - Response from Barking Havering and Redbridge NHS Trust
Open published response
×
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 Assign sole responsibility and ownership for Controlled Medication Keys to identified individuals at the start of each shift.
Verbatim wording from the response “A change in the process of Controlled Medication Keys is already in place since the incident, with individuals identified at the start of each shift with sole responsibility and ownership of these.” Source location 2024-0360 - Response from Barking Havering and Redbridge NHS Trust
Open published response
×
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 Operate a Quarterly Health Records Group to present and review best practice and learning opportunities.
Verbatim wording from the response “In August 2024, the Medical Directorate has established a Quarterly Health Records Group where both best practice and learning opportunities will be presented and reviewed with action plans as appropriate.” Source location 2024-0360 - Response from Barking Havering and Redbridge NHS Trust
Open published response
20 Oct 2023 Thomas Doyle · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Poor standard of clinical records View source Failure to commence a diagnostic pathway for suspected sepsis when indicated View source
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Thomas Doyle · 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
Thomas Doyle, a 90-year-old man, was admitted to hospital with back and chest pain and subsequently developed sepsis while in hospital, dying on 25 January 2023. The concerns included poor clinical records and failure to commence the diagnostic pathway for sepsis when indicated on admission, contrary to local policy and national guidance.
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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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Poor standard of clinical records
Wider context from the report “1. The trust’s clinical records were of a particularly poor standard which impeded the Trust’s governance investigation and the inquest investigation in determining what, if any considerations was given to the possibility that Mr Doyle was suffering from an infection.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to commence a diagnostic pathway for suspected sepsis when indicated
Wider context from the report “2. The Trust’s failure to commence a diagnostic pathway to investigate sepsis when clearly indicated on Mr Doyle’s admission , as required by both local policy and national guidance.
” 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 Provide regular weekly sepsis teaching sessions in Acute Medicine across both sites.
Verbatim wording from the response “• Acute Medicine have regular weekly teaching sessions within which sepsis is the most regular topic on both sites.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit electronic sepsis-suspicion documentation monthly and report compliance through established assurance arrangements.
Verbatim wording from the response “• There is a mandatory field on the new electronic record asking the question 'is sepsis suspected' if yes this triggers the sepsis pathway and data is captured that way. Monthly audit of this takes place with the latest results showing 100% compliance of the records audited.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Trust sepsis education programme and provide additional face-to-face training for doctors and nurses.
Verbatim wording from the response “• The Trust sepsis education programme is essential for all clinical staff and has recently been updated. This is supported by additional face to face training for doctors and nurses.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct and report an Emergency Department medical-records audit of Careflow free-text completion, with oversight by the Trust Audit Committee.
Verbatim wording from the response “• ED services have registered a medical records audit which will commence December 2023 and complete 31 January 2024, on the new electronic Careflow record, ensuring the free text sections are being completed to the Trust and professional standards. The audit report will be shared with all teams and action plan agreed for any identified areas of concern; the audit will be overseen by the Trust Audit Committee.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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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 Adopt the UK Sepsis Trust adult screening tool and audit its use, high-risk patients and positive blood-culture compliance with the Sepsis 6.
Verbatim wording from the response “• The Trust has adopted the UK Sepsis Trust’s adult screening tool and the use of this is audited by the Lead Nurse for Sepsis. Audits include patients who have scored over 5 on the National Early Warning Score to ensure that Sepsis was considered. In addition, all positive blood culture cases are audited to ensure compliance with the Sepsis 6.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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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 Use a mandatory electronic sepsis-suspicion field that triggers the sepsis pathway and captures compliance data.
Verbatim wording from the response “• There is a mandatory field on the new electronic record asking the question 'is sepsis suspected' if yes this triggers the sepsis pathway and data is captured that way. Monthly audit of this takes place with the latest results showing 100% compliance of the records audited.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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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 Require medical staff record-keeping e-learning from their first working day and include record keeping in nursing preceptorship and junior-doctor induction.
Verbatim wording from the response “• All medical staff must complete a record keeping module on the Trust BEST learning management system that allows staff to undertake e learning module on their first day working at the Trust. Record keeping for nursing staff is included in the nursing preceptorship programme.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
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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 Disseminate record-keeping standards and safety concerns through staff alerts, intranet video, computer screensavers and clinical governance meetings.
Verbatim wording from the response “• An Internal Alert has been shared with staff via email, Alert reference ████████ Issued Date 9 November 2023 which details good record keeping standards that should be adhered to by all staff.” Source location Response from Barking, Havering and Redbridge University Hospitals NHS Trust
Open published response
29 Sep 2023 Marion May Luckraft · Prevention of Future Deaths report East London
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Concerns raised 5 Delays in execution of treatments View source Fragmentation of treatment across two sites View source Absence of a clear and workable treatment pathway for biliary sepsis View source Failure to promptly escalate care to a high dependency unit despite a NEWS score of 8 View source Delays in execution of diagnostic processes View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Marion May Luckraft · 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
Marion May Luckraft was admitted to hospital with jaundice and died on 17 April 2023 after developing a duodenal perforation following ERCP and pancreatic stent placement, biliary sepsis and shock. The principal concerns were cumulative delays in diagnostic and treatment processes, delayed escalation to high dependency care, fragmented treatment across two hospital sites, and the absence of a clear treatment pathway for biliary sepsis.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in execution of treatments
Wider context from the report “1. Cumulative delays in the execution of diagnostic processes and treatments of the patient probably increased the risk of Mrs Luckraft developing biliary sepsis.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Fragmentation of treatment across two sites
Wider context from the report “3. The fragmentation of the patient’s treatment across two sites of the Trust contributed to delays in her treatment.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a clear and workable treatment pathway for biliary sepsis
Wider context from the report “4. The absence of a clear and workable treatment pathway for biliary sepsis contributed to delays.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to promptly escalate care to a high dependency unit despite a NEWS score of 8
Wider context from the report “2. Following the duodenal perforation suffered by the patient there was a failure to promptly escalate her care to a high dependency unit despite her NEWS score of 8 .
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in execution of diagnostic processes
Wider context from the report “1. Cumulative delays in the execution of diagnostic processes and treatments of the patient probably increased the risk of Mrs Luckraft developing biliary sepsis.
” Open source report
20 Jul 2023 Peter John Harris · Prevention of Future Deaths report City of London
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Concerns raised 2 Failure to alert requesting teams to suspicious radiological findings treated as expected findings View source Failure to require use of read receipts for radiology reports View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Peter John Harris · 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
Peter John Harris was admitted with stage 4 metastatic lung cancer and recurrent pericardial effusion, suffered a cardiac arrest during treatment, developed multi-organ failure, and died on 10 June 2022. The principal concerns were that two scans with concerning findings were not seen and acted upon in a timely manner, including a 2020 scan indicating possible lung metastases and a 2022 scan suspicious for lung cancer. Ongoing concerns remained about whether unexpected or expected cancer findings would be appropriately highlighted and whether optional read receipts would adequately identify unread reports.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to alert requesting teams to suspicious radiological findings treated as expected findings
Wider context from the report “Concern 1:
The Trust’s new policy is concerned with ensuring that unexpected cancer or other critical radiological findings are highlighted to the requesting team. However, the evidence at the inquest suggested that requesting team were not alerted to the suspicious outcome of the Deceased’s November 2020 scan because it was an expected finding; as stated above, I was told that the radiologist’s report was not escalated or alerted to the clinical or multi-disciplinary teams because the requesting form had indicated that the scan was to rule out malignancy and the outcome was not, therefore, treated as unexpected . I am concerned, therefore, that the same could happen again , despite the changes which have been made. I did not consider that ████████ was able to address this concern satisfactorily in his evidence.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to require use of read receipts for radiology reports
Wider context from the report “Concern 2:
The new electronic system is introducing a “read receipt” feature which, if used, would enable identification of reports which have not been opened and read by the requesting team in a timely manner. I am concerned, however, that the use of the read receipt is optional as this will inevitably undermine the extent to which any monitoring system will be able to spot and identify unread reports . I did not consider that either ████████, nor the Consultant Colorectal Surgeon from whom I heard evidence about the plans for monitoring in the surgical department of Queens Hospital, were able to address this concern satisfactorily in their evidence.
” 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 Launch the Aptvision radiology referral system during the week commencing 30 October 2023.
Verbatim wording from the response “1. Aptvision Radiology Referral System – this new Radiology Requesting System is planned to live week commencing 30 October 2023.” Source location Response from Barking, Havering and Redbridge University Hospitals
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add the radiological requesting, review, and expectation process to the Chief Medical Officer’s three-day induction programme for new consultants.
Verbatim wording from the response “The Radiological Requesting, Review and Expectation process as detailed in this response will be added to the New Consultants 3-day Induction programme run by the CMO.” Source location Response from Barking, Havering and Redbridge University Hospitals
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a unified North-East London cancer-alert policy through collaborative clinical leadership work.
Verbatim wording from the response “7. Collaborative Working - On 04 July 2023 Dr Ghadge, Consultant Radiologist and Clinical Lead for Radiology, presented the BHRUT’s Policy on Incidental Finding at the North-East London (NEL) Clinical Leadership Group for peer review. This group’s membership comprises of the Quality and Safety Leads (Consultant grade) from Whipps Cross Hospital, St Bartholomew Hospital, the Royal London Hospital, the Homerton and Newham Hospital. The progress made by BHRUT was recognised and the group members agreed to devise a Unified Incidental Finding Policy across NEL. At the last meeting (01 September 2023), it was agreed that a policy for Cancer Alerts would be developed whereas Critical non-cancer alerts would vary as per local needs. The next meeting planned is 01 December 2023.” Source location Response from Barking, Havering and Redbridge University Hospitals
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide specialty access to reports identifying unacknowledged results and issue fortnightly updates highlighting reports unread after seven days for governance oversight.
Verbatim wording from the response “4. Oversight of Reporting - Speciality Specific Reports – Requesting Specialties will be provided with direct access to Business Information (BI) reports summarising a list of patients for whom results have not been acknowledged by the requesting clinician. Once access has been provided, each of the Clinical Groups (CGs) will use the information for local discussion and management through their own Governance/ Quality and Safety meetings. A fortnightly status update will be produced and fed back to each of the CGs/ Specialties highlighting those reports that have not been read at 7 days. It is anticipated that the SitRep will include:” Source location Response from Barking, Havering and Redbridge University Hospitals
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide an electronic acknowledgement function for referrers to confirm receipt of finalised radiology reports and urgent notifications, supported by user training.
Verbatim wording from the response “2. Acknowledgement Feature – Following a finalised radiological report, alongside any urgent notifications produced by radiology, an “acknowledgment” button is available. The “acknowledgment” button functionality allows all referrers involved in the initial radiology request to electronically select and acknowledge the receipt of the patient’s radiological report. The referral portal⁴ training material and learning outcomes for users, will emphasise the requirement of acknowledging results.” Source location Response from Barking, Havering and Redbridge University Hospitals
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Alert referrers electronically to expected, unexpected, and newly detected cancers and critical or significant non-cancer findings, with verbal escalation for emergency findings.
Verbatim wording from the response “1. The Radiology department will alert/notify the referrer’s/requesters to all imaging with:” Source location Response from Barking, Havering and Redbridge University Hospitals
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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 Require specialties to create shared mailboxes receiving imaging-report notifications alongside named consultants’ individual worklists.
Verbatim wording from the response “5. Speciality Specific Mailboxes – will be created by the Specialties. This is as an additional safeguard where the notification of imaging report will be sent to a group email in addition to the named consultants individual worklist. Access to shared mailbox will be agreed by the Specialty.” Source location Response from Barking, Havering and Redbridge University Hospitals
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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 Requesting doctors and clinical teams are responsible for promptly reading and acting on radiology reports and fail-safe alerts, including leave cover.
Verbatim wording from the response “It is the responsibility of the requesting doctor and/or their clinical team to read and act upon the report findings and fail-safe alerts as quickly and efficiently as possible. This extends to ensuring robust mechanisms are in place and resourced to cover leave within clinical teams or practices.” Source location Response from Barking, Havering and Redbridge University Hospitals
Open published response
29 Jun 2023 Mr Matthew John Phipps · Prevention of Future Deaths report East London
View report summary
Concerns raised 1 Lack of a contingency plan for providing intensive care when the intensive care unit is full View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Mr Matthew John Phipps · 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
Matthew Phipps was admitted to hospital with severe acute kidney injury and symptoms associated with likely sepsis, and was recognised as critically unwell. There were delays in transferring him to intensive care, administering antibiotics, monitoring him, carrying out blood tests and commencing renal replacement therapy; the inquest found that these failings did not contribute to his death. A concern arose about the lack of a contingency plan for providing intensive care when the intensive care unit is full.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a contingency plan for providing intensive care when the intensive care unit is full
Wider context from the report “A concern arose at the Inquest hearing in relation to the lack of a contingency plan in place to ensure that intensive care is provided to all patients who require it, but where the intensive care unit itself is full . The Inquest heard evidence from an independent consultant anaesthetist who stated:
I do not understand why one or two of the 8 ICU patients who were deemed to be wardable, could not have been moved elsewhere (e.g. to a post anaesthetic care unit in an operating suite), to enable a sick patient such as Mr Phipps to be admitted to the ICU . It is my understanding that most ICUs have such contingency plans in place, in the form of agreed standard operating procedures .
The Trust were aware of this concern, but did not provide any evidence to address this.
” Open source report
18 Apr 2023 John Edward Stiff · Prevention of Future Deaths report East London
View report summary
Concerns raised 1 Insufficient orthogeriatric provision for elderly orthopaedic trauma patients with comorbidities View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
John Edward Stiff · 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
John Edward Stiff was admitted to Queen's Hospital after a believed unwitnessed fall and was diagnosed with an undisplaced pelvic fracture. His condition declined, including reduced appetite and a chest infection, and he died at the hospital on 16 November 2022. The report raised concerns that patients with hip and pelvic fractures and age-related co-morbidities would be better cared for by orthogeriatricians, and that limited access to such care could contribute to untimely deaths.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient orthogeriatric provision for elderly orthopaedic trauma patients with comorbidities
Wider context from the report “The Inquest heard evidence from an orthopaedic surgeon that patients such as Mr Stiff, who suffer hip and pelvic fractures and who have a number of additional age-related co-morbidities, would be best cared for by ortho-geriatricians . The inquest heard that this matter has been raised by the orthopaedic team on multiple occasions, but the orthogeriatric provision has not been increased .
The Inquest also heard that the lack of orthogeriatric provision is a national issue of concern within the NHS .
Orthopaedic trauma in elderly patients often exacerbates underlying medical conditions . Orthogeriatric trained staff would be better trained to recognise and treat medical co-morbidities . It is therefore considered that improved access to orthogeriatric care for this patient cohort could prevent future untimely deaths.
” Open source report
6 Mar 2023 Maureen Edna Dick · Prevention of Future Deaths report East London
View report summary
Concerns raised 4 Lack of a system for mandatory pressure ulcer training View source Lack of professional curiosity in investigating causes of severe pain View source Failure to diagnose osteomyelitis View source Failure to adequately assess sacral pressure ulcers View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Maureen Edna Dick · 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
Maureen Edna Dick was admitted to hospital with likely sepsis and was at high risk of developing a pressure ulcer. A pressure ulcer developed and deteriorated, with concerns including inadequate risk assessment, repositioning, assessment and investigation, and failure to diagnose osteomyelitis before transfer. She died at Broomfield Hospital from her infected hospital-acquired pressure ulcer; the inquest concluded that her death was contributed to by neglect.
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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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for mandatory pressure ulcer training
Wider context from the report “4. There is no system for mandatory training for clinical staff in relation to pressure ulcers .
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of professional curiosity in investigating causes of severe pain
Wider context from the report “1. There was a lack of professional curiosity by the medical staff in relation to investigating the cause of Mrs Dick’s severe pain in October 2021.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to diagnose osteomyelitis
Wider context from the report “3. There was a failure to diagnose Osteomyelitis at Queens Hospital prior to her transfer to Broomfield Hospital on the 29th October 2021.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately assess sacral pressure ulcers
Wider context from the report “2. There was a failure by the medical staff to adequately assess the sacral pressure ulcer between the 24th October to 29th October 2021, particularly in light of the increasing white cell count and severe pain complained of by Mrs Dick .
” Open source report
9 Feb 2023 George Frederick Kearsey · Prevention of Future Deaths report East London
View report summary
Concerns raised 4 Failure to put fluid balance charts in place View source Failure of consultant-led ward rounds to adequately review fluid monitoring View source Poor maintenance of clinical records of fluid administration View source Failure to administer IV fluids consistently View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
George Frederick Kearsey · 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
George Frederick Kearsey sustained injuries in a fall at home, was admitted to hospital, developed aspiration pneumonia, and died on the evening of 8 June 2022. Concerns included inconsistent administration of IV fluids, missing fluid balance charts, poorly maintained clinical records, and inadequate review of fluid monitoring during consultant-led ward rounds.
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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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to put fluid balance charts in place
Wider context from the report “2. Contrary to Trust policy, fluid balance charts were not put in place to assess Mr Kearsey’s fluid intake and output .
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of consultant-led ward rounds to adequately review fluid monitoring
Wider context from the report “4. Consultant-led ward rounds did not adequately review fluid monitoring .
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Poor maintenance of clinical records of fluid administration
Wider context from the report “3. Clinical records were poorly maintained , resulting in an unclear picture of fluid administration .
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to administer IV fluids consistently
Wider context from the report “1. IV fluids were not administered consistently . The longest period in which fluids were not administered was 17 hours and 45 minutes.
” Open source report
4 Nov 2022 Peter Mantador Ross · Prevention of Future Deaths report East London
View report summary
Concerns raised 6 Poor maintenance of clinical records View source Failure to accurately report CT C-spine findings View source Failure to escalate identified CT Spine abnormalities to other clinicians View source Failure to record identified CT Spine abnormalities View source Repeated failures in communication between clinical teams and staff View source Failure to review CT C-spine images before burr-hole surgery View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Peter Mantador Ross · 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
Peter Mantador Ross sustained a subdural haemorrhage and cervical spine fracture after falling down stairs at home on 8 July 2020. The spinal fracture was misinterpreted and remained undiagnosed; later failures to maintain immobilisation and delays in MRI contributed to cardiac arrest and severe neurological injury. He subsequently developed pneumonia following an aspiration episode, and the inquest found that neglect contributed to his death. Concerns also included failures to review and communicate CT findings and poor clinical record-keeping.
Read the report on judiciary.uk
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Poor maintenance of clinical records
Wider context from the report “1. A CT C-spine requested on the admission on 8 July 2020 was misreported as normal.
2. Following that report, during the initial referral of Mr Ross to neurosurgery, the reviewing surgeon noticed an abnormality in Mr Ross’s CT Spine, made no note of his finding and did not escalate his finding to any other clinician.
3. Prior to burr-hole surgery, the neurosurgical team did not review the CT C spine images.
1. A CT C-spine requested on the admission on 8 July 2020 was misreported as normal.
2. Following that report, during the initial referral of Mr Ross to neurosurgery, the reviewing surgeon noticed an abnormality in Mr Ross’s CT Spine, made no note of his finding and did not escalate his finding to any other clinician.
3. Prior to burr-hole surgery, the neurosurgical team did not review the CT C spine images.
4. Repeated failures in communication between; neurosurgical, emergency medicine, nursing staff, and physiotherapists led to serious harm to Mr Ross.
5. Clinical records were poorly maintained , exacerbating the lapses in communication between those treating Mr Ross.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately report CT C-spine findings
Wider context from the report “1. A CT C-spine requested on the admission on 8 July 2020 was misreported as normal.
2. Following that report, during the initial referral of Mr Ross to neurosurgery, the reviewing surgeon noticed an abnormality in Mr Ross’s CT Spine, made no note of his finding and did not escalate his finding to any other clinician.
3. Prior to burr-hole surgery, the neurosurgical team did not review the CT C spine images.
1. A CT C-spine requested on the admission on 8 July 2020 was misreported as normal.
2. Following that report, during the initial referral of Mr Ross to neurosurgery, the reviewing surgeon noticed an abnormality in Mr Ross’s CT Spine, made no note of his finding and did not escalate his finding to any other clinician.
3. Prior to burr-hole surgery, the neurosurgical team did not review the CT C spine images.
4. Repeated failures in communication between; neurosurgical, emergency medicine, nursing staff, and physiotherapists led to serious harm to Mr Ross.
5. Clinical records were poorly maintained, exacerbating the lapses in communication between those treating Mr Ross.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate identified CT Spine abnormalities to other clinicians
Wider context from the report “1. A CT C-spine requested on the admission on 8 July 2020 was misreported as normal.
2. Following that report, during the initial referral of Mr Ross to neurosurgery, the reviewing surgeon noticed an abnormality in Mr Ross’s CT Spine, made no note of his finding and did not escalate his finding to any other clinician.
3. Prior to burr-hole surgery, the neurosurgical team did not review the CT C spine images.
1. A CT C-spine requested on the admission on 8 July 2020 was misreported as normal.
2. Following that report, during the initial referral of Mr Ross to neurosurgery, the reviewing surgeon noticed an abnormality in Mr Ross’s CT Spine, made no note of his finding and did not escalate his finding to any other clinician.
3. Prior to burr-hole surgery, the neurosurgical team did not review the CT C spine images.
4. Repeated failures in communication between; neurosurgical, emergency medicine, nursing staff, and physiotherapists led to serious harm to Mr Ross.
5. Clinical records were poorly maintained, exacerbating the lapses in communication between those treating Mr Ross.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record identified CT Spine abnormalities
Wider context from the report “1. A CT C-spine requested on the admission on 8 July 2020 was misreported as normal.
2. Following that report, during the initial referral of Mr Ross to neurosurgery, the reviewing surgeon noticed an abnormality in Mr Ross’s CT Spine, made no note of his finding and did not escalate his finding to any other clinician.
3. Prior to burr-hole surgery, the neurosurgical team did not review the CT C spine images.
1. A CT C-spine requested on the admission on 8 July 2020 was misreported as normal.
2. Following that report, during the initial referral of Mr Ross to neurosurgery, the reviewing surgeon noticed an abnormality in Mr Ross’s CT Spine, made no note of his finding and did not escalate his finding to any other clinician.
3. Prior to burr-hole surgery, the neurosurgical team did not review the CT C spine images.
4. Repeated failures in communication between; neurosurgical, emergency medicine, nursing staff, and physiotherapists led to serious harm to Mr Ross.
5. Clinical records were poorly maintained, exacerbating the lapses in communication between those treating Mr Ross.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Repeated failures in communication between clinical teams and staff
Wider context from the report “1. A CT C-spine requested on the admission on 8 July 2020 was misreported as normal.
2. Following that report, during the initial referral of Mr Ross to neurosurgery, the reviewing surgeon noticed an abnormality in Mr Ross’s CT Spine, made no note of his finding and did not escalate his finding to any other clinician.
3. Prior to burr-hole surgery, the neurosurgical team did not review the CT C spine images.
1. A CT C-spine requested on the admission on 8 July 2020 was misreported as normal.
2. Following that report, during the initial referral of Mr Ross to neurosurgery, the reviewing surgeon noticed an abnormality in Mr Ross’s CT Spine, made no note of his finding and did not escalate his finding to any other clinician.
3. Prior to burr-hole surgery, the neurosurgical team did not review the CT C spine images.
4. Repeated failures in communication between; neurosurgical, emergency medicine, nursing staff, and physiotherapists led to serious harm to Mr Ross.
5. Clinical records were poorly maintained, exacerbating the lapses in communication between those treating Mr Ross.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review CT C-spine images before burr-hole surgery
Wider context from the report “1. A CT C-spine requested on the admission on 8 July 2020 was misreported as normal.
2. Following that report, during the initial referral of Mr Ross to neurosurgery, the reviewing surgeon noticed an abnormality in Mr Ross’s CT Spine, made no note of his finding and did not escalate his finding to any other clinician.
3. Prior to burr-hole surgery, the neurosurgical team did not review the CT C spine images.
1. A CT C-spine requested on the admission on 8 July 2020 was misreported as normal.
2. Following that report, during the initial referral of Mr Ross to neurosurgery, the reviewing surgeon noticed an abnormality in Mr Ross’s CT Spine, made no note of his finding and did not escalate his finding to any other clinician.
3. Prior to burr-hole surgery, the neurosurgical team did not review the CT C spine images.
4. Repeated failures in communication between; neurosurgical, emergency medicine, nursing staff, and physiotherapists led to serious harm to Mr Ross.
5. Clinical records were poorly maintained, exacerbating the lapses in communication between those treating Mr Ross.
” Open source report
×
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 Provide non-consultant clinical staff training in authoritative reporting, empowerment and escalation, including formal induction for new doctors.
Verbatim wording from the response “The neurosurgery department has reflected on this finding and will be providing training to all non-consultant grade clinical staff in authoritative reporting as well as support with techniques regarding empowerment and escalation to ensure that any future concerns are raised to the appropriate responsible consultant. This training will focus on resilience, good communication and empowerment to speak out or challenge areas of potential failings. The department will closely monitor training outcomes for success (at LFG and M&M meetings) and will implement formal training as part of local induction for new doctors.” Source location Response from Barking, Havering and Redbridge University Hospitals
Open published response
×
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 Implement an electronic patient record system to improve access to records, communication, decision-making and patient planning.
Verbatim wording from the response “orientation of our records system. The Trust is currently in the process of implementing electronic patient record system. The purpose of the new system is to provide clinicians with an easier to access tool to aid good communication, decision making and clear patient planning.” Source location Response from Barking, Havering and Redbridge University Hospitals
Open published response
×
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 Complete all Radiology Department actions assigned through the Trust’s serious incident recommendations and subsequent action plan.
Verbatim wording from the response “1) The Trust fully accepts that the CT C-Spine requested on 08 July 2020 was mis-reported as normal. The Radiology Department has completed all the actions assigned to the department within the Trust’s SI recommendations and subsequent Action Plan. If any scan is mis-reported, the Department uses it as a learning opportunity, and it is reviewed at the Departmental Radiology Event and Learning Meeting (REALM) and undertakes a process of peer review. The Radiology Department has reviewed Mr Ross’s scans through its Governance process.” Source location Response from Barking, Havering and Redbridge University Hospitals
Open published response
×
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 Develop improved multidisciplinary communication through cross-disciplinary meetings, agreed action planning and hybrid meeting formats.
Verbatim wording from the response “4) The department has reflected on this finding and is developing better communication methods with all stakeholders and colleagues. This includes inviting clinical colleagues to local M&M, MDT and Clinical Governance meetings to discuss cases that include multiple disciplines for learning and agreed action planning. MDT’s are now in a hybrid format which incorporates virtual and face to face meetings offering flexibility for a wider range of stakeholder attendance.” Source location Response from Barking, Havering and Redbridge University Hospitals
Open published response
×
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 Audit documentation on the trauma neurosurgical pathway and provide refresher and induction training on record keeping.
Verbatim wording from the response “5) The department recognise there were failures in the standard of medical record keeping for this case. The neurosurgical specialty has taken this very seriously and will undertake documentation audit on the trauma neurosurgical pathway. Routine refresher training will be made available as well as training during local induction for new staff. This includes” Source location Response from Barking, Havering and Redbridge University Hospitals
Open published response
×
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 Review mis-reported scans through departmental learning meetings and peer review.
Verbatim wording from the response “1) The Trust fully accepts that the CT C-Spine requested on 08 July 2020 was mis-reported as normal. The Radiology Department has completed all the actions assigned to the department within the Trust’s SI recommendations and subsequent Action Plan. If any scan is mis-reported, the Department uses it as a learning opportunity, and it is reviewed at the Departmental Radiology Event and Learning Meeting (REALM) and undertakes a process of peer review. The Radiology Department has reviewed Mr Ross’s scans through its Governance process.” Source location Response from Barking, Havering and Redbridge University Hospitals
Open published response
×
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 The reviewing surgeon examined the scans and informed the on-call Consultant of the cervical spine abnormality.
Verbatim wording from the response “In this case, the reviewing surgeon who received the referral for Mr Ross did look at the scans and did inform the Consultant of his concerns. The Consultant on call was therefore aware and made decisions on management.” Source location Response from Barking, Havering and Redbridge University Hospitals
Open published response
18 Jul 2022 Mr Graham Edgar White · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Lack of a registry of patients fitted with stents for monitoring and recall View source Failure to identify and escalate deaths through governance procedures as serious incidents for investigation View source Failure to assess whether patients with stents inserted prior to May 22 are at risk of similar deterioration View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Graham Edgar White · 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
Mr Graham Edgar White was treated for a ureteric stone in November 2019 with an antegrade ureteric stent intended for temporary use. The stent remained in place for 20 months despite deterioration observed on multiple occasions, and was removed after he developed a urinary tract infection and right perinephric abscess. He developed sepsis and died in hospital on 18 August 2021. Concerns included the absence of a stent registry for monitoring and recall, uncertainty about other patients at risk, and delayed identification of the death as a serious incident.
Read the report on judiciary.uk
× 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a registry of patients fitted with stents for monitoring and recall
Wider context from the report “1. Trust did not have in place a registry of those fitted with stents that would facilitate monitoring and recall of patients .
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and escalate deaths through governance procedures as serious incidents for investigation
Wider context from the report “3. The Trust did not successfully identify and escalate this death through its governance procedures as a serious incident for investigation until the issue was raised by the Coroner .
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess whether patients with stents inserted prior to May 22 are at risk of similar deterioration
Wider context from the report “2. At the time of the inquest the Trust are unable to assess whether they have patients with stents inserted prior to May 22 who are at risk of a similar deterioration .
” 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 Implement and operate an electronic ureteric stent register with automated population, overdue warnings and weekly monitoring.
Verbatim wording from the response “This led to the development and implementation of a new electronic stent register which can track and warn staff of stents that are about to become overdue so appropriate actions can be taken. This stent register went live in August 2022.” Source location Response from Barking, Havering and Redbridge University Hospitals
Open published response
×
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 Complete a retrospective review of stent insertions from 1 April 2019 to 5 August 2022 to identify missed patients and tracking gaps.
Verbatim wording from the response “To ensure there were no other patients with stents that were missed, the Trust committed to carrying out a retrospective review of all stents inserted over the preceding 3 years. This was done to ensure any patients that had been missed could be contacted and appropriate harm reviews carried out so these patients can be treated appropriately and as quickly as possible. To provide a robust mechanism of tracking and assurance a retrospective review of all stent insertions was conducted for patients attending BHRUT between 1st April 2019 and 5th August 2022.” Source location Response from Barking, Havering and Redbridge University Hospitals
Open published response
×
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 Review governance procedures for detecting potential incidents and emphasise internal incident reporting within clinical divisions.
Verbatim wording from the response “In respect of the Coroner’s concern around the Trust’s delay in identifying this as a serious incident for investigation, whilst a serious incident report was completed, which has resulted in key actions and recommendations described above, that process should have commenced at an earlier stage and in accordance with the BHRUT’s own governance procedures. BHRUT has reviewed its governance procedures for the detection of potential incidents and via the Quality and Safety Team, the need to internally report incidents has been emphasised within the Divisions. In addition, BHRUT has introduced incident reporting of all new inquests to formalise divisional review, with the aim of capturing any incidents that may not have been incident reported prior to the opening of an inquest.” Source location Response from Barking, Havering and Redbridge University Hospitals
Open published response
×
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 Introduce incident reporting for all new inquests to formalise divisional review and identify previously unreported incidents.
Verbatim wording from the response “In respect of the Coroner’s concern around the Trust’s delay in identifying this as a serious incident for investigation, whilst a serious incident report was completed, which has resulted in key actions and recommendations described above, that process should have commenced at an earlier stage and in accordance with the BHRUT’s own governance procedures. BHRUT has reviewed its governance procedures for the detection of potential incidents and via the Quality and Safety Team, the need to internally report incidents has been emphasised within the Divisions. In addition, BHRUT has introduced incident reporting of all new inquests to formalise divisional review, with the aim of capturing any incidents that may not have been incident reported prior to the opening of an inquest.” Source location Response from Barking, Havering and Redbridge University Hospitals
Open published response
25 May 2022 Elizabeth Margaret Mills · Prevention of Future Deaths report East London
View report summary
Concerns raised 5 Failure to explore family members’ views during the do-not-attempt-CPR process View source Poor medical record-keeping and documentation of do-not-attempt-CPR decisions View source Failure to properly engage the do-not-attempt-CPR process View source Failure to investigate unexpected care-impacting events through Serious Incident Investigation View source Reliance on a family member to maintain oxygen mask placement View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Elizabeth Margaret Mills · 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
Elizabeth Margaret Mills was admitted to hospital with abdominal pain on 25 March 2021, underwent surgery for a perforated pyloric ulcer, and later developed pneumonia requiring increasing oxygen therapy. She died after removing an oxygen mask while unattended in a side ward, when nasal cannulae were replaced but were no longer connected to an oxygen supply. Concerns included poor medical record-keeping about the do-not-attempt-CPR process, reliance on her husband to keep the mask in place, and the Trust’s failure to investigate unexpected events through a Serious Incident Investigation.
Read the report on judiciary.uk
× 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to explore family members’ views during the do-not-attempt-CPR process
Wider context from the report “1. The poor standard of medical record-keeping and documentation did not allow a clear understanding of whether the Trust policy on “Do not attempt CPR” orders was followed properly. Family members assert that the process was not properly engaged and their views were not explored .
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Poor medical record-keeping and documentation of do-not-attempt-CPR decisions
Wider context from the report “1. The poor standard of medical record-keeping and documentation did not allow a clear understanding of whether the Trust policy on “Do not attempt CPR” orders was followed properly. Family members assert that the process was not properly engaged and their views were not explored.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to properly engage the do-not-attempt-CPR process
Wider context from the report “1. The poor standard of medical record-keeping and documentation did not allow a clear understanding of whether the Trust policy on “Do not attempt CPR” orders was followed properly . Family members assert that the process was not properly engaged and their views were not explored.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate unexpected care-impacting events through Serious Incident Investigation
Wider context from the report “3. Unexpected events that impacted upon Mrs Mills’ care were not investigated by the Trust in the form of a Serious Incident Investigation.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Reliance on a family member to maintain oxygen mask placement
Wider context from the report “2. During the final hours of her life, Mrs Mills required increasing levels of oxygen therapy. Mrs Mills was agitated and repeatedly removed her venturi mask. Medical and nursing staff left Mrs Mills in a side ward in the care of her husband, relying upon him to ensure her mask remained in place.
” 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 Remind nursing staff of expectations for safely caring for patients receiving oxygen therapy.
Verbatim wording from the response “The expectation is that if a nurse leaves the patient, they will notify the patient/relative/visitor of where they are going, how long they will be and to call, if assistance is required. Nursing staff will be reminded of the expectations involved in nursing patients receiving oxygen therapy.” Source location Response from NHS Barking, Havering and Redbridge University Hospital
Open published response
×
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 Ratify a new DNACPR policy.
Verbatim wording from the response “The Trust is satisfied that the current policy (attached to this response) clearly sets out the need for clear communication about DNACPR with the patient and those close to them, together with the need for clear documentation on DNACPR decisions and the requirement for regular review of DNACPR decisions. I am sorry that the documentation in this case did not allow a clear understanding of whether the Trust policy on DNACPR orders was correctly followed. The Trust intends to ratify a new DNACPR policy in August 2022. Policies undergo rigorous drafting with stakeholder engagement, to aid richer development. Policies are disseminated across the Trust in discussion by virtual meetings, relevant forums such as Quality and Safety meetings, emails cascaded by Divisional teams and through briefings by the Communications Team.” Source location Response from NHS Barking, Havering and Redbridge University Hospital
Open published response
×
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 The current DNACPR policy sufficiently requires communication, documentation and regular review of CPR decisions.
Verbatim wording from the response “The Trust is satisfied that the current policy (attached to this response) clearly sets out the need for clear communication about DNACPR with the patient and those close to them, together with the need for clear documentation on DNACPR decisions and the requirement for regular review of DNACPR decisions. I am sorry that the documentation in this case did not allow a clear understanding of whether the Trust policy on DNACPR orders was correctly followed. The Trust intends to ratify a new DNACPR policy in August 2022. Policies undergo rigorous drafting with stakeholder engagement, to aid richer development. Policies are disseminated across the Trust in discussion by virtual meetings, relevant forums such as Quality and Safety meetings, emails cascaded by Divisional teams and through briefings by the Communications Team.” Source location Response from NHS Barking, Havering and Redbridge University Hospital
Open published response
×
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 The incident did not require a Serious Incident investigation because reviews concluded it was not a Serious Incident matter.
Verbatim wording from the response “The incident was reported on 26 March 2021 and it was flagged as a potential SI matter by the Quality and Safety ‘Q&S’ Team. A review was undertaken by the ED Matron and by the Surgical Division. This was held with multidisciplinary key stakeholders from including pharmacists, matrons, registrars, clinical leads, consultants and consultant surgeons from Gastroenterology, Breast and General Surgery, Adult Day Unit and Theatres. The reviews established that the correct morphine doses were given to EM at appropriate times and the matter was not an SI matter. The Q&S team removed the potential SI flag. Separately, EM’s husband pursued a complaint regarding her care and management which was not upheld and the husband declined a meeting with the Trust.” Source location Response from NHS Barking, Havering and Redbridge University Hospital
Open published response
×
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 In acute deterioration, it may not be possible to provide additional staff to supervise a patient removing oxygen therapy.
Verbatim wording from the response “care to assist with giving oxygen therapy safely. However, in an acute situation, such as EM’s situation, where the patient deteriorates quickly, it may not be possible to facilitate extra staff and the focus would be on providing immediate treatment. It is expected that nursing staff would escalate the fact that a patient is agitated and removing their oxygen mask to the doctor/nurse in charge. It would be reasonable for a nurse to leave the patient for a short period in order to communicate with colleagues/escalate any concerns, if the patient was settled. Patients’ relatives can be very helpful in reassuring and calming patients to assist with giving therapies such as oxygen but there would not be an assumption that they would deal with administering the therapy.” Source location Response from NHS Barking, Havering and Redbridge University Hospital
Open published response
14 Oct 2021 Louie Neil Johnston · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Failure to ensure medical staff complete mandated annual CTG training View source Failure of CTG monitoring equipment to keep the CTG trace clearly visible during delivery View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Louie Neil Johnston · 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
Louie Neil Johnston died in hospital on 28 April 2020 from diffuse hypoxic ischaemic encephalopathy caused by inadequate oxygen supply to his brain during delivery. The report identified avoidable delivery delays, limitations in CTG monitoring equipment, and gaps in mandatory CTG training for staff.
Read the report on judiciary.uk
× 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure medical staff complete mandated annual CTG training
Wider context from the report “2. A review of staff training records indicated that an obstetric registrar involved in the delivery was not up to date with mandated annual CTG training . Additionally, the obstetric consultant had not completed annual training which required the session to be repeated following the death of Louie Johnston. Systems in place at the Trust did not ensure that all medical staff had completed requisite training .
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of CTG monitoring equipment to keep the CTG trace clearly visible during delivery
Wider context from the report “1. CTG trace monitoring equipment that was in use in the labour ward required staff to switch from a CTG trace screen to a K2 electronic recording screen during delivery . This meant that a graphic representation of the CTG trace was not clearly visible at all times . Instead, midwifery staff were required to crouch down and record numeric data from the CTG displayed on a small LED screen. The Trust identified this as counter-productive and raised the issue with the manufacturer of the system. To date, the system has not been updated .
” Open source report
12 Oct 2021 Mrs Vivien Brunning · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Omissions of prescribed daily low molecular weight heparin injections View source Failure to report noticed medication omissions through the incident reporting system View source Failure to undertake required venous thromboembolism reviews at 24 and 72 hours following admission View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mrs Vivien Brunning · 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
Mrs Vivien Brunning was admitted to hospital with sepsis and treated for a kidney stone, during which prescribed Clexane was temporarily held and then omitted on 13 and 14 July 2020. She developed a right brachial artery thrombosis, suffered a stroke during emergency thrombolysis, and died on 25 July 2020. Concerns included missed venous thromboembolism reviews, omitted anticoagulant doses, and failure to report the initial omission through the Trust’s incident reporting system.
Read the report on judiciary.uk
× 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Omissions of prescribed daily low molecular weight heparin injections
Wider context from the report “2. Prescribed daily injections of low molecular weight heparin were omitted on 13th and 14th July 2020
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to report noticed medication omissions through the incident reporting system
Wider context from the report “3. The initial omission on 13th July 2020 was noticed by a ward doctor but was not reported through the Trust’s incident reporting system .
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake required venous thromboembolism reviews at 24 and 72 hours following admission
Wider context from the report “1. The hospital notes demonstrate that required venous thromboembolism reviews at 24 & 72 hrs following admission were not undertaken .
” Open source report
18 May 2021 Juliet Saunders · Prevention of Future Deaths report East London
View report summary
Concerns raised 8 Serious Incident Investigation process failing to identify significant care failings and produce a good-quality report View source Poor medical record keeping and documentation in the emergency department and observation unit View source Failure to recognise abnormal findings on abdominal radiographs View source Failure of systems to provide supervision and escalation of complex cases involving junior doctors View source Absence of emergency department staff support for patients with learning disability during weekends View source Lack of clinical curiosity and failure to reconsider a queried diagnosis when findings are inconsistent View source Absence of safety-netting advice for patients leaving the hospital View source Departure from established procedures for safe transfers from the emergency department to the observation unit View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Juliet Saunders · 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
Juliet Saunders, a 25-year-old woman with Cornelia De Lange Syndrome and a profound learning disability, attended hospital on 7 March 2020 with abdominal pain and vomiting and died at home the following day. The report identified concerns including misinterpretation of abdominal x-rays, failure to diagnose intestinal obstruction, inadequate escalation and supervision, departures from transfer and discharge procedures, lack of safety-netting advice, and insufficient support for patients with learning disabilities at weekends.
Read the report on judiciary.uk
× 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Serious Incident Investigation process failing to identify significant care failings and produce a good-quality report
Wider context from the report “8. Ineffective identification of significant failings in care delivered through the Trust’s own Serious Incident Investigation process , leading to a finalised report of poor quality.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Poor medical record keeping and documentation in the emergency department and observation unit
Wider context from the report “2. The poor standard of medical record keeping and documentation within the emergency department and observation unit.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise abnormal findings on abdominal radiographs
Wider context from the report “4. Consecutive failures by medical and radiological staff to recognise abnormal findings within an abdominal radiograph , impacted upon by diagnostic overshadowing.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of systems to provide supervision and escalation of complex cases involving junior doctors
Wider context from the report “3. The failure of systems within the department to allow for the supervision of junior doctors to ensure that complex cases are escalated to more experienced staff.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of emergency department staff support for patients with learning disability during weekends
Wider context from the report “1. The absence of any support for staff within the emergency department during weekends, in dealing with patients with learning disability.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clinical curiosity and failure to reconsider a queried diagnosis when findings are inconsistent
Wider context from the report “5. A lack of clinical curiosity, combined with diagnostic overshadowing meant that there was a reluctance to depart from a queried diagnosis of gastritis which led to the failure to diagnose an acute intestinal obstruction.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of safety-netting advice for patients leaving the hospital
Wider context from the report “7. The absence of safety-netting advice to patients leaving the hospital.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Departure from established procedures for safe transfers from the emergency department to the observation unit
Wider context from the report “6. A departure from established procedures to ensure the safety of transfers out of the emergency department to the observation unit.
” 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 Commission and complete an external review of serious-incident reports, policies and procedures.
Verbatim wording from the response “• The Trust commissioned an external maternity review in March 2021, into Serious Incidents (SIs) from the period of January 2019 to December 2020. The review involved a structured review of SI reports as well as a review of SI related policies and procedures at the Trust. This was in conjunction with a series of semi structured interviews with staff at all levels of the Trust as well as site visits during which more informal conversations with staff and patients took place. The final report has now been received by the Trust. This will enable the Trust to undertake a review of existing systems and processes, and the opportunity to plan positive actions as well as planning for the transition to the new national policy framework, particularly the new Patient Safety Incident Response Framework (PSIRF), set to be rolled out nationally from spring next year.” Source location 2021-0157-Response-from-Queens-Hospital_Published
Open published response
×
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 Maintain monthly nursing documentation audits and a peer-review process between both Emergency Departments.
Verbatim wording from the response “• There are routine nursing documentation audits in place which are completed monthly and a peer review process has now been established between both Emergency Departments.” Source location 2021-0157-Response-from-Queens-Hospital_Published
Open published response
×
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 Introduce consultant clinical-note reviews and direct feedback through supervision and appraisal meetings.
Verbatim wording from the response “• There is a plan in place for Consultants to deliver clinical notes reviews as part of their supervisor meetings, with the next meeting to be held in August 2021. The Trust acknowledges that there has been some capacity issues which have impacted on the supervisors meetings, due to the impact of the Covid pandemic. The process will be part of supervisors meetings and will now be officially part of the appraisal process. The ED Consultant Clinical Supervisors plan to review 10 records of their supervisees notes and providing them direct feedback about their document which is led by a dedicated ED Consultant.” Source location 2021-0157-Response-from-Queens-Hospital_Published
Open published response
×
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 Launch a patient-designed discharge safety-netting leaflet after final approval and printing.
Verbatim wording from the response “• A discharge leaflet has been designed in partnership with patients which provides information on discharge. This will be launched shortly once the final approval has been signed off and the leaflet has returned from the printers. In addition to the leaflet, the Emergency Department are trialling a Discharge Helpline this is planning to launch from Monday 12th July and will provide a number to call if they have any queries after discharge. There is a draft SOP for the 2 month pilot period.” Source location 2021-0157-Response-from-Queens-Hospital_Published
Open published response
×
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 Launch and weekly-audit a two-month Emergency Department discharge helpline pilot.
Verbatim wording from the response “• A discharge leaflet has been designed in partnership with patients which provides information on discharge. This will be launched shortly once the final approval has been signed off and the leaflet has returned from the printers. In addition to the leaflet, the Emergency Department are trialling a Discharge Helpline this is planning to launch from Monday 12th July and will provide a number to call if they have any queries after discharge. There is a draft SOP for the 2 month pilot period.” Source location 2021-0157-Response-from-Queens-Hospital_Published
Open published response
×
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 Use Care Flow to require consultant sign-off for specified patients and senior review before learning-disability patient discharge.
Verbatim wording from the response “• There has been reinforcement with the junior staff that there can be no handovers between FY2 level doctors and any handover should be to a Tier 2 doctor at a minimum. There is a dedicated handover Standard Operating Procedure (SOP). We have now installed a new IT system called Care Flow which requires Consultant sign off for specific patients such as patients with learning disability, cardiac chest pain and all patients that were seen by junior Doctors; i.e. FY2 and SHO.” Source location 2021-0157-Response-from-Queens-Hospital_Published
Open published response
×
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 Deliver teaching on diagnostic overshadowing and senior escalation, and add safeguarding and diagnostic overshadowing to the induction pack.
Verbatim wording from the response “• There has been a teaching session based on this case which highlighted the need to discuss patients with a learning disability with a senior team due to the risk of diagnostic overshadowing. This was presented in the January 2021 Mortality meeting. This included reference to escalation and consideration of CT scan and specific reference to Cornelia de Lange syndrome.” Source location 2021-0157-Response-from-Queens-Hospital_Published
Open published response
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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 Run a weekly task-and-finish group and audits to improve discharge and transfer documentation compliance across both sites.
Verbatim wording from the response “• A weekly task and finish group was set up which was set up led and chaired by the DDON with all Lead Nurses and Matrons attending. Part of its remit was to review our compliance on both sites. Part of its remit has been to review our discharge and transfer compliance on both sites; the Matrons have completed their own weekly audits. We were keen to improve our compliance and tackle our underlying issues and deliver sustained care to our patients.” Source location 2021-0157-Response-from-Queens-Hospital_Published
Open published response
×
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 Continue recruiting a Lead Learning Disabilities nurse and use a newly developed career map to attract staff.
Verbatim wording from the response “• The Learning Disability (LD) Team provides an advisory service to support clinical teams during the hours of 09:00 - 17:00, Monday to Friday. To increase the cover to include weekends would require an increase in the LD establishment. The Trust has recently attempted to recruit a Lead Learning Disabilities nurse, however following three attempts; it has not been possible to find candidates with suitable experience to fulfil the requirements of the role. In addition to this, there has been a reduction in student applications for the learning disability nursing cohorts nationally. However, the Trust will continue with its recruitment to the post and has again advertised for this position in July 2021. The Trust has also developed a learning Disability Career map to attract staff into the Trust.” Source location 2021-0157-Response-from-Queens-Hospital_Published
Open published response
×
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 Provide documentation training through handovers, training sessions and staff discussions.
Verbatim wording from the response “• A Senior Sister and the Practice Development Nurse (PDN) have provided training on documentation. They have been speaking to staff during handovers, training sessions and impromptu discussions.” Source location 2021-0157-Response-from-Queens-Hospital_Published
Open published response
×
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 Provide weekly virtual teaching on radiographic assessment and related diagnostic issues.
Verbatim wording from the response “• There is ongoing training and this has been added to the teaching rotation. Teaching takes place every Thursday and is done virtually to accommodate staff that cannot be present on site.” Source location 2021-0157-Response-from-Queens-Hospital_Published
Open published response
×
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 Develop a guideline with Radiology and General Surgery to replace plain abdominal radiographs with CT for specified acute abdominal presentations.
Verbatim wording from the response “• Radiology clinical leads are in discussion with ED department to remove plain abdominal radiographs in assessing patients presenting with acute abdominal pain due to issues with low specificity and sensitivity. This would be in line with the recent GIRFT report in radiology and are meeting with ED to progress this.
The ED department will be using CT scans for acute abdominal pain and clinically obstructed abdomens instead as sensitivity and specificity are much higher. The department has had discussions with the Radiology department and we need to involve general surgery to complete a new guideline. This should be complete by mid-August and the next meeting is scheduled for next week (W/C 19 July 2021).” Source location 2021-0157-Response-from-Queens-Hospital_Published
Open published response
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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 Serious Incident governance arrangements remain paused because COVID-19 released clinical staff and the Trust awaits national guidance, although reports are being progressed.
Verbatim wording from the response “During the Covid pandemic governance arrangements, including SI reports were placed on hold, to allow for clinical staff to be released to support ward areas. The pause is still in place (the declaration of SIs or Never Event continues) however the Trust is taking proactive steps to ensure reports are still being progressed in line with reporting requirements, which the Trust is awaiting guidance from NHSEI and the CCG.” Source location 2021-0157-Response-from-Queens-Hospital_Published
Open published response
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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 Weekend Learning Disability Team cover cannot currently be increased because it requires additional establishment and suitable recruitment has been unsuccessful.
Verbatim wording from the response “• The Learning Disability (LD) Team provides an advisory service to support clinical teams during the hours of 09:00 - 17:00, Monday to Friday. To increase the cover to include weekends would require an increase in the LD establishment. The Trust has recently attempted to recruit a Lead Learning Disabilities nurse, however following three attempts; it has not been possible to find candidates with suitable experience to fulfil the requirements of the role. In addition to this, there has been a reduction in student applications for the learning disability nursing cohorts nationally. However, the Trust will continue with its recruitment to the post and has again advertised for this position in July 2021. The Trust has also developed a learning Disability Career map to attract staff into the Trust.” Source location 2021-0157-Response-from-Queens-Hospital_Published
Open published response
6 Nov 2020 Stanley Alfred Babbs · Prevention of Future Deaths report East London
View report summary
Concerns raised 4 Failure to identify a responsible clinician for contrast administration View source Administration of contrast media without a formal prescription View source Lack of careful consideration of contrast medium dose View source Lack of prescribing safeguards for patients at higher risk of contrast induced acute kidney injury View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Stanley Alfred Babbs · 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
Stanley Alfred Babbs, who had chronic kidney disease, diabetes and heart failure, became unwell after receiving contrast for a CT scan and was diagnosed with contrast-induced acute kidney injury. He was later admitted to hospital and died from sepsis arising from a urinary tract infection on 16 February 2016. The report raised concerns that contrast, a prescription-only medicine, could be administered without a formal prescription, individualised risk/benefit assessment, careful dose consideration or a clearly identified responsible clinician, particularly for patients at high risk of acute kidney injury.
Read the report on judiciary.uk
× 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify a responsible clinician for contrast administration
Wider context from the report “The Royal College of Radiologist Standards for Intravascular Contrast Administration requires that the ultimate responsibility for intravascular contrast administration rests with the person who prescribes it .
The Standards identify risk factors for acute kidney injury, to include chronic kidney disease (eGFR of less than 40); heart failure and age 75 years or older. The Standards identify that for those at risk of acute kidney injury, the dose of non-ionic iodine based contrast medium should be minimised, taking into consideration the indication and patient's body weight.
It was noted at the Inquest hearing that a Practice Group Direction has been prepared for the administration of contrast to persons who are not at increased risk (those with an eGFR greater than 30). There is no such Practice Group Direction or other prescribing safeguards for patients at higher risk (eGFR lower than 30).
The clinical lead for radiology at the Trust stated in his oral evidence that there is no prescription for contrast. This is so, even though contrast is a prescription only medicine. The clinical lead stated that a radiologist will simply say “contrast” or “no contrast”. This is the case even for those patients who have a high risk of a contrast induced acute kidney injury.
Patients with chronic kidney disease, diabetes, cardiac failure and aged over 75 have an up to 25% risk of a contrast induced acute kidney injury. In these circumstances, it is concerning that contrast media (a prescription only medicine) can be administered without a formal prescription, evidence of a careful consideration of the dose and a clearly identified responsible clinician.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Administration of contrast media without a formal prescription
Wider context from the report “The Royal College of Radiologist Standards for Intravascular Contrast Administration requires that the ultimate responsibility for intravascular contrast administration rests with the person who prescribes it.
The Standards identify risk factors for acute kidney injury, to include chronic kidney disease (eGFR of less than 40); heart failure and age 75 years or older. The Standards identify that for those at risk of acute kidney injury, the dose of non-ionic iodine based contrast medium should be minimised, taking into consideration the indication and patient's body weight.
It was noted at the Inquest hearing that a Practice Group Direction has been prepared for the administration of contrast to persons who are not at increased risk (those with an eGFR greater than 30). There is no such Practice Group Direction or other prescribing safeguards for patients at higher risk (eGFR lower than 30).
The clinical lead for radiology at the Trust stated in his oral evidence that there is no prescription for contrast . This is so, even though contrast is a prescription only medicine. The clinical lead stated that a radiologist will simply say “contrast” or “no contrast”. This is the case even for those patients who have a high risk of a contrast induced acute kidney injury.
Patients with chronic kidney disease, diabetes, cardiac failure and aged over 75 have an up to 25% risk of a contrast induced acute kidney injury. In these circumstances, it is concerning that contrast media (a prescription only medicine) can be administered without a formal prescription , evidence of a careful consideration of the dose and a clearly identified responsible clinician.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of careful consideration of contrast medium dose
Wider context from the report “The Royal College of Radiologist Standards for Intravascular Contrast Administration requires that the ultimate responsibility for intravascular contrast administration rests with the person who prescribes it.
The Standards identify risk factors for acute kidney injury, to include chronic kidney disease (eGFR of less than 40); heart failure and age 75 years or older. The Standards identify that for those at risk of acute kidney injury, the dose of non-ionic iodine based contrast medium should be minimised, taking into consideration the indication and patient's body weight .
It was noted at the Inquest hearing that a Practice Group Direction has been prepared for the administration of contrast to persons who are not at increased risk (those with an eGFR greater than 30). There is no such Practice Group Direction or other prescribing safeguards for patients at higher risk (eGFR lower than 30).
The clinical lead for radiology at the Trust stated in his oral evidence that there is no prescription for contrast. This is so, even though contrast is a prescription only medicine. The clinical lead stated that a radiologist will simply say “contrast” or “no contrast”. This is the case even for those patients who have a high risk of a contrast induced acute kidney injury.
Patients with chronic kidney disease, diabetes, cardiac failure and aged over 75 have an up to 25% risk of a contrast induced acute kidney injury. In these circumstances, it is concerning that contrast media (a prescription only medicine) can be administered without a formal prescription, evidence of a careful consideration of the dose and a clearly identified responsible clinician.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of prescribing safeguards for patients at higher risk of contrast induced acute kidney injury
Wider context from the report “The Royal College of Radiologist Standards for Intravascular Contrast Administration requires that the ultimate responsibility for intravascular contrast administration rests with the person who prescribes it.
The Standards identify risk factors for acute kidney injury, to include chronic kidney disease (eGFR of less than 40); heart failure and age 75 years or older. The Standards identify that for those at risk of acute kidney injury, the dose of non-ionic iodine based contrast medium should be minimised, taking into consideration the indication and patient's body weight.
It was noted at the Inquest hearing that a Practice Group Direction has been prepared for the administration of contrast to persons who are not at increased risk (those with an eGFR greater than 30). There is no such Practice Group Direction or other prescribing safeguards for patients at higher risk (eGFR lower than 30).
The clinical lead for radiology at the Trust stated in his oral evidence that there is no prescription for contrast. This is so, even though contrast is a prescription only medicine. The clinical lead stated that a radiologist will simply say “contrast” or “no contrast”. This is the case even for those patients who have a high risk of a contrast induced acute kidney injury.
Patients with chronic kidney disease, diabetes, cardiac failure and aged over 75 have an up to 25% risk of a contrast induced acute kidney injury. In these circumstances, it is concerning that contrast media (a prescription only medicine) can be administered without a formal prescription, evidence of a careful consideration of the dose and a clearly identified responsible clinician.
” Open source report
×
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 Require an ED clinician’s prescription for intravenous contrast for specified direct-access scans, recording it in the notes and RIS as an interim measure.
Verbatim wording from the response “• Scans on direct access pathway from ED which need contrast e.g. CT Angiogram for stroke will require a prescription for contrast in the patients notes. (As per action 9 on plan)” Source location 2020-0225-Response-from-Barking-Havering-and-Redbridge-University-Hospitals-Redacted.pdf
Open published response
×
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 Specify contrast dosing at 1 ml/kg up to a 100 ml maximum.
Verbatim wording from the response “• Contrast Dose: now specified as 1ml/Kg with maximum of 100ml (medical scales have been ordered for all scanners and should be in place soon). (As per action 12 on plan)” Source location 2020-0225-Response-from-Barking-Havering-and-Redbridge-University-Hospitals-Redacted.pdf
Open published response
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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 Create a prescription sheet within the PGD for patients with eGFR below 30 or risk factors outside the PGD.
Verbatim wording from the response “• Prescriptions for CT IV contrast for patients with eGFR < 30 to ensure these requests are appropriately authorised. (As per action 4 on Plan)” Source location 2020-0225-Response-from-Barking-Havering-and-Redbridge-University-Hospitals-Redacted.pdf
Open published response
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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 Obtain approval for radiographer PGDs and update the internal protocol to permit contrast injection on a radiologist’s prescription for eGFR 30–45.
Verbatim wording from the response “• Practice Group Direction (“PGD”) approval for Radiographers/updating internal protocol to enable Radiographers to inject IV contrast on a Radiologist’s prescription, for patients with eGFR between 30 and 45” Source location 2020-0225-Response-from-Barking-Havering-and-Redbridge-University-Hospitals-Redacted.pdf
Open published response
×
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 Communicate to radiologists the requirement for personalised assessment of patients receiving intravenous contrast with eGFR below 30 and multiple risk factors.
Verbatim wording from the response “The following actions have been implemented to ensure safe practice with all patients undergoing a CT scan with IV contrast.” Source location 2020-0225-Response-from-Barking-Havering-and-Redbridge-University-Hospitals-Redacted.pdf
Open published response
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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 Introduce a radiology request form containing safeguards for abnormal renal function, contrast indication and patient discussion.
Verbatim wording from the response “• Creating a new Radiology request form to incorporate safeguards for patients with abnormal renal function and to confirm that the clinician has indicated the use of contrast and if a discussion has taken place with the patient about the use of contrast.” Source location 2020-0225-Response-from-Barking-Havering-and-Redbridge-University-Hospitals-Redacted.pdf
Open published response
×
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 Provide medical scales for all scanners to support the specified contrast dosing.
Verbatim wording from the response “• Contrast Dose: now specified as 1ml/Kg with maximum of 100ml (medical scales have been ordered for all scanners and should be in place soon). (As per action 12 on plan)” Source location 2020-0225-Response-from-Barking-Havering-and-Redbridge-University-Hospitals-Redacted.pdf
Open published response
×
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 Record radiologist contrast-authorisation decisions on request forms or the RIS, including decisions for patients with eGFR below 30.
Verbatim wording from the response “The following actions have been implemented to ensure safe practice with all patients undergoing a CT scan with IV contrast.” Source location 2020-0225-Response-from-Barking-Havering-and-Redbridge-University-Hospitals-Redacted.pdf
Open published response
21 Oct 2020 Roger Wood · Prevention of Future Deaths report East London
View report summary
Concerns raised 1 Reliance on GP assessment and referral within the AAA treatment pathway View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Roger Wood · 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
Roger Wood had been monitored for an abdominal aortic aneurysm, which measured 5.5 cm in June 2017. The scan result was sent to his GP but was not acted upon, and he was not referred for specialist treatment. He later died from a fatal rupture of the aneurysm on 12 February 2019. The principal concern was that the treatment pathway relied on a GP referral link that could fail, allowing vital diagnostic information not to be acted upon.
Read the report on judiciary.uk
× 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Reliance on GP assessment and referral within the AAA treatment pathway
Wider context from the report “In 2017, the policy in place was for AAA ultrasound scan results to be sent to the patient’s GP for assessment. The GP was to decide whether to refer the patient for treatment.
In Mr Wood’s case, the GP either overlooked the results or considered them and determined that the size of the AAA did not require follow-up treatment. In either scenario, vital diagnostic information was not acted upon with a fatal result.
In the light of the sad facts of Mr Wood’s death, Barking, Havering and Redbridge University NHS Trust have now changed Trust policy. Now when a patient is identified to have a AAA equal or greater than 5.5cm results include auto mailed to make a vascular referral are not simply sent to a GP electronically, they are also emailed. This change undoubtedly improves matters, but does not entirely eliminate the risk of these tragic circumstances being repeated by directly triggering a referral.
My concern is that the current treatment pathway contains a possibly redundant link, the role of the GP. A link, which as demonstrated in Mr Wood’s case, is capable of failure.
” Open source report
19 Dec 2019 Doris Daisy Laura Clark · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Failure to identify pre-hospital opiate doses and unit discrepancies View source Use of different units for opiate medication between pre-hospital services and hospitals View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Doris Daisy Laura Clark · 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
Doris Daisy Laura Clark fell at home on 3 November 2018 and remained on the floor for around six hours before being taken to hospital with a suspected fractured neck of femur. She received multiple doses of morphine, including an intravenous dose that was not titrated, and was not monitored in accordance with Trust policy; concerns included inconsistent use of millilitres and milligrams between pre-hospital and hospital services when recording opiate medication.
Read the report on judiciary.uk
× 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify pre-hospital opiate doses and unit discrepancies
Wider context from the report “The doctor who prescribed the morphine at Queens Hospital had not appreciated that the London Ambulance Service paramedics had administered 20 milligrams of morphine. If he had been aware of this he would have administered a further 10 milligrams. The doctor did not note that the paramedics had referred to mls as opposed to mgs in the medication section of the Patient Report Form. The doctor confirmed that the units used in hospital are mgs.
It was agreed by all witnesses that great care needs to be taken in the administration of opiate medication. It was agreed that the use of different units by the pre-hospital service and the hospitals themselves creates risk and creates concern as to the risk of future deaths. It is requested that the Trust liaise with the London Ambulance Service to determine whether the units for administration of opiate medication can be standardised between the hospitals and pre-hospital services.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Use of different units for opiate medication between pre-hospital services and hospitals
Wider context from the report “The doctor who prescribed the morphine at Queens Hospital had not appreciated that the London Ambulance Service paramedics had administered 20 milligrams of morphine. If he had been aware of this he would have administered a further 10 milligrams. The doctor did not note that the paramedics had referred to mls as opposed to mgs in the medication section of the Patient Report Form. The doctor confirmed that the units used in hospital are mgs.
It was agreed by all witnesses that great care needs to be taken in the administration of opiate medication. It was agreed that the use of different units by the pre-hospital service and the hospitals themselves creates risk and creates concern as to the risk of future deaths . It is requested that the Trust liaise with the London Ambulance Service to determine whether the units for administration of opiate medication can be standardised between the hospitals and pre-hospital services.
” Open source report
Concerns raised 6 Failure to conduct a serious incident report into a preventable death View source Failure of neuroradiological review to identify and flag critical intracranial pressure indicators View source Delay in availability of neuroradiological reports for key neurosurgical consultations View source Failure to seek specialist ophthalmic advice View source Failure to obtain the outcome of external ophthalmic assessments View source Risk of fatal respiratory depression and further intracranial pressure elevation from opioid analgesia in raised intracranial pressure View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sam Antony Crick · 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
Sam Antony Crick, aged 24, developed recurrent hydrocephalus and progressively raised intracranial pressure before a catastrophic collapse on 29 February 2016. He underwent emergency neurosurgical intervention but died at Addenbrookes Hospital on 4 March 2016. The concerns included missed radiological and ophthalmological signs of rising intracranial pressure, delays in obtaining and considering important imaging information, and the absence of a serious incident investigation.
Read the report on judiciary.uk
× 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct a serious incident report into a preventable death
Wider context from the report “(A).This was a significant adverse event and the death was preventable. However, there have been no serious incident report (SIR) into the death . The importance of the SIR process is to consider root causes and importantly, to make recommendations and implement an action plan. Learning lessons is a key feature of the process.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of neuroradiological review to identify and flag critical intracranial pressure indicators
Wider context from the report “(B). The neuroradiological review of the CT scan in November 2015 and early December 2015 did not highlight the obvious brain parenchymal herniation through the pre-existing burr hole as well as other interval change and this was a missed opportunity of flagging a clear indicator of rising intracranial pressure . Furthermore, there is now a separate investigation on the death of another person (SP) where involvement of the neuroradiology department at the Queens hospital is a central issue.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delay in availability of neuroradiological reports for key neurosurgical consultations
Wider context from the report “(C). The last face to face consultation between the Neurosurgeon and the deceased was on the 3rd February 2016 but the written neuroradiological report of the January 26th CT scan was not available until the 4th February 2016 and so this report was not considered by the Neurosurgeon as it was not available for this key consultation . This report did highlight some alarming features of herniation but this vital information was therefore not considered.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to seek specialist ophthalmic advice
Wider context from the report “(D). The consultant neurosurgeons examination on the 2nd December 2015 did not find frank papilledema and yet an examination by a consultant ophthalmologist at the Luton and Dunstable hospital on the 18th November 2015 and 24th December 2015 had found papilledema at both appointments. The consultant neurologist’s referral letter from Luton and Dunstable indicated a finding of papilledema also and stated an ophthalmic review was being sought but there appears to have been no attempt to find the outcome of the Luton assessments. Further, and in the alternative, no specialist ophthalmic advice was sought by the neurosurgeon even though there had been lengthy ophthalmic follow up over a number of years after the third ventriculostomy in 2007 and also given the recorded findings of the consultant neurologist in Luton.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain the outcome of external ophthalmic assessments
Wider context from the report “(D). The consultant neurosurgeons examination on the 2nd December 2015 did not find frank papilledema and yet an examination by a consultant ophthalmologist at the Luton and Dunstable hospital on the 18th November 2015 and 24th December 2015 had found papilledema at both appointments. The consultant neurologist’s referral letter from Luton and Dunstable indicated a finding of papilledema also and stated an ophthalmic review was being sought but there appears to have been no attempt to find the outcome of the Luton assessments . Further, and in the alternative, no specialist ophthalmic advice was sought by the neurosurgeon even though there had been lengthy ophthalmic follow up over a number of years after the third ventriculostomy in 2007 and also given the recorded findings of the consultant neurologist in Luton.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Risk of fatal respiratory depression and further intracranial pressure elevation from opioid analgesia in raised intracranial pressure
Wider context from the report “(F). A point explored in the investigation was the administration of opioid analgesia in someone who has raised intracranial pressure . This was looking at an opiate acting as a respiratory depressant with a consequent rise in the level of carbon dioxide in the blood which in turn could further raise ICP provoked by hypercapnia . This could cause a fatality . Luton and Dunstable hospital have designed a standard operating procedure to address this and it raises a question of whether this should be distributed nationally so as to achieve consistency of approach.
” 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 Make recommendations to prevent recurrence of the identified examination and specialist-advice failures.
Verbatim wording from the response “The Consultant Neurosurgeon involved in these examinations is no longer practicing in the Trust and is therefore unable to personally comment. These failures are however, being investigated as part of the ongoing SIR and recommendations will be made to ensure that these issues do not happen again.” Source location 2017-0457-Response-by-Barking-Havering-and-Redbridge-University-Hospitals-NHS-Trust
Open published response
×
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 Review externally reported deaths weekly through Morbidity and Mortality sessions, identify lessons and provide feedback to referring hospitals.
Verbatim wording from the response “It is normal practice for the Division to discuss all deaths at the Trust within 30 days of death and where indicated to notify of a potential SI in accordance with the Trust’s Incident & Serious Incident Policy. At the time of Sam’s death the Trust had no process to review externally reported deaths. This will be addressed in the SIR with a recommendation that all externally reported deaths are reviewed weekly as part of a Morbidity and Mortality session to identify any lessons and feedback to referring hospitals.” Source location 2017-0457-Response-by-Barking-Havering-and-Redbridge-University-Hospitals-NHS-Trust
Open published response
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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 Cascade standards for clinicians on making radiology requests.
Verbatim wording from the response “Responsibility for following up imaging requests rests with the requester and the Trust accepts that in Sam’s case, the imaging was not available for his clinic appointment on 3 February 2017 as it should have been. In reviewing radiology processes the Trust has identified the need to improve the quality of radiology requests. On 17 August the Medical Director cascaded to all clinical staff a set of standards expected of clinicians in making a radiology request. A copy of the email dated 17 August 2017 is attached for your information.” Source location 2017-0457-Response-by-Barking-Havering-and-Redbridge-University-Hospitals-NHS-Trust
Open published response
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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 Investigate the identified examination and specialist-advice failures through the ongoing Significant Incident investigation.
Verbatim wording from the response “The Consultant Neurosurgeon involved in these examinations is no longer practicing in the Trust and is therefore unable to personally comment. These failures are however, being investigated as part of the ongoing SIR and recommendations will be made to ensure that these issues do not happen again.” Source location 2017-0457-Response-by-Barking-Havering-and-Redbridge-University-Hospitals-NHS-Trust
Open published response
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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 Complete the ongoing Significant Incident investigation into the death.
Verbatim wording from the response “Following receipt of the Coroner’s Regulation 28 report a Significant Incident (SI) notification was completed by the Division and an SI declared by the Trust’s corporate team on 31 August 2017. SI investigations are currently ongoing and the report will be shared with the Clinical Commissioning Groups (CCG’s); Barking, Havering and Redbridge Clinical Commissioning Group (BHRCCG) and North East London Commissioning Support Group (NELCSU) on or before 23 November 2017. The CCG’s then has 20 days to consider the report and agree the findings.” Source location 2017-0457-Response-by-Barking-Havering-and-Redbridge-University-Hospitals-NHS-Trust
Open published response
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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 The Trust disputes that the missed brain herniation finding was obvious, stating that this was an exceptionally rare complication.
Verbatim wording from the response “The neuro-radiological review of the CT scans in November 2015 and early December 2015 did not highlight the brain parenchymal herniation through the re-existing burr hole as this finding was missed. This is an exceptionally rare complication; the Neuro-radiologist who reported the scan and who has 17 years of experience as a Consultant Neuro-radiologist has never previously encountered this complication. The Trust acknowledges this finding was missed by the reporting Neuro-radiologist but does not accept that the finding was ‘obvious’ as suggested.” Source location 2017-0457-Response-by-Barking-Havering-and-Redbridge-University-Hospitals-NHS-Trust
Open published response
15 Jun 2017 Mr Kevin George Mann · Prevention of Future Deaths report East London
View report summary
Concerns raised 6 Failure to abandon the procedure after contrast entered the left main bronchus View source Failure to avoid the swallow procedure in the presence of a left pneumothorax View source Failure to adequately review the Visipaque procedure policy View source Visipaque procedure policy failing to require contrast documentation and preliminary checks View source Failure to check recent radiology before commencing the swallow procedure View source Failure to document the amount of contrast handed over and ingested View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Kevin George Mann · 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
Mr Kevin George Mann underwent an Ivor Lewis procedure for oesophageal cancer and subsequently developed a pneumothorax. A Visipaque contrast study was performed despite the pneumothorax, and contrast entered his left main bronchus; his respiratory condition deteriorated and he later died. Concerns included failures to check available imaging and an outstanding chest x-ray request, to stop the procedure when contrast entered the bronchus, and to document the amount of contrast used.
Read the report on judiciary.uk
× 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to abandon the procedure after contrast entered the left main bronchus
Wider context from the report “3. The radiologist continued with the procedure after becoming aware of the passage of contrast material into the left main bronchus . The consultant surgeon and independent radiologist confirmed that the procedure should have been abandoned at that stage .
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to avoid the swallow procedure in the presence of a left pneumothorax
Wider context from the report “1. An independent radiology expert confirmed that the left pneumothorax was clearly apparent from the imaging, prior to the swallow commencing . The independent expert, consultant surgeon and consultant intensivist all agreed that the procedure should not have been carried out, in light of the pneumothorax .
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately review the Visipaque procedure policy
Wider context from the report “5. The policy in place regarding the Visipaque procedure does not require documentation of the amount of contrast material used, or for preliminary checks to be undertaken. The incident occurred over a year ago. Despite clear concerns being raised by the Consultant surgeon on 27 May 2016, there had been no adequate review of the Visipaque procedure policy, by the date of the Inquest hearing .
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Visipaque procedure policy failing to require contrast documentation and preliminary checks
Wider context from the report “5. The policy in place regarding the Visipaque procedure does not require documentation of the amount of contrast material used, or for preliminary checks to be undertaken . The incident occurred over a year ago. Despite clear concerns being raised by the Consultant surgeon on 27 May 2016, there had been no adequate review of the Visipaque procedure policy, by the date of the Inquest hearing.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to check recent radiology before commencing the swallow procedure
Wider context from the report “2. The radiologist who performed the procedure did not check the radiology system prior to commencing the swallow procedure . Had she checked the system she would have seen the x-ray taken at 12:37 showing the large left pneumothorax. She would also have seen the outstanding request for a chest x-ray. Both the independent radiology expert and the Trust radiology witness (Dr G), confirmed that recent radiology should be checked by the radiologist prior to performing this procedure .
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document the amount of contrast handed over and ingested
Wider context from the report “4. There was no documentation available within the records of the amount of contrast handed to Mr Mann or the amount of contrast ingested by him .
” 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 Implement the revised Visipaque protocol requiring specific informed consent and communication between radiologists and referring clinicians before investigations.
Verbatim wording from the response “The Trust’s Radiology Department has carried out an audit of Visipaque Swallows from May 2016 – June 2017 and will conduct a further audit three months after the revised Protocol (attached) has come into use to ensure understanding and compliance. If any issues are identified by the audit, the staff concerned will have 1:1 conversations with one of the Clinical Leads for Radiology and be required to undergo an observed procedure for assurance of skill.” Source location 2017-0190-Response-by-Barking-Havering-and-Redbridge-NHS-Trust
Open published response
10 Mar 2017 Mrs Anna Teresa Walker · Prevention of Future Deaths report East London
View report summary
Concerns raised 8 Failure to document post-operative checks View source Chaotic transfer pathway for radiology patients to the ward View source Incident investigation failing to identify deficient post-operative care View source Failure to carry out compliant post-operative checks View source Unavailability of an appropriate environment for post-operative monitoring View source Failure of porters to collect post-procedure patients View source Failure of ward nurses to receive post-procedure patients View source Unclear post-procedure clinical accountability View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Mrs Anna Teresa Walker · 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
Mrs Anna Teresa Walker underwent a liver biopsy on 8 July 2016 and suffered a bleed caused by a tear to the hepatic artery. She died in hospital the following morning after a significant delay in detecting the bleed. The principal concerns were that required post-operative checks were not carried out, monitoring responsibilities were unclear, and the appropriate environment for post-operative monitoring was not provided.
Read the report on judiciary.uk
× 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document post-operative checks
Wider context from the report “1. The Consultant Radiologist who performed the procedure confirmed that the post-operative checks were not compliant with the Trust’s Protocol. Only 2 complete checks were carried out (at 10:45 and 11 am). The check at 11:50 was not complete. There were no further post-operative checks documented on the observation sheet after 11:50 , despite the concerning observations at that time. The Consultant Radiologist gave evidence that had the appropriate post-operative checks been carried out, the bleed was likely to have been detected at an earlier stage. He further confirmed that had the bleed been detected at an earlier stage Mrs Walker’s death is likely to have been avoided on the 9th July 2016.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Chaotic transfer pathway for radiology patients to the ward
Wider context from the report “2. The Consultant Radiologist confirmed that in his opinion, the reasons for the failure to carry out the required observations were:
I. The failure of the porters to collect the patient. He stated that the failure of the porters to attend, was reported as a serious incident. He stated that this issue has still not been resolved and is an ongoing issue within the Trust.
II. The failure of nurses on the ward to take her back. (Albeit the evidence revealed that the nurses on the ward were concerned about her low blood pressure).
III. The Consultant described a “chaotic situation” with patients coming in for treatment to the radiology department but patients not going up to the ward .
IV. He stated that Mrs Walker was not in the appropriate environment for post-operative monitoring.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Incident investigation failing to identify deficient post-operative care
Wider context from the report “5. 2 incident report forms were completed in relation to Mrs Walker’s death. (Form number 52695 and Form number 53952). The outcome of the main incident report form (52695) concluded that appropriate care was given and this was not considered a Serious Incident . This conclusion was at odds with the evidence heard from the Trust’s Consultant Radiologist . It was also at odds with the Trust’s Protocol for post-operative monitoring and the recorded post-operative observations .
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out compliant post-operative checks
Wider context from the report “1. The Consultant Radiologist who performed the procedure confirmed that the post-operative checks were not compliant with the Trust’s Protocol . Only 2 complete checks were carried out (at 10:45 and 11 am). The check at 11:50 was not complete . There were no further post-operative checks documented on the observation sheet after 11:50, despite the concerning observations at that time. The Consultant Radiologist gave evidence that had the appropriate post-operative checks been carried out, the bleed was likely to have been detected at an earlier stage. He further confirmed that had the bleed been detected at an earlier stage Mrs Walker’s death is likely to have been avoided on the 9th July 2016.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of an appropriate environment for post-operative monitoring
Wider context from the report “2. The Consultant Radiologist confirmed that in his opinion, the reasons for the failure to carry out the required observations were:
I. The failure of the porters to collect the patient. He stated that the failure of the porters to attend, was reported as a serious incident. He stated that this issue has still not been resolved and is an ongoing issue within the Trust.
II. The failure of nurses on the ward to take her back. (Albeit the evidence revealed that the nurses on the ward were concerned about her low blood pressure).
III. The Consultant described a “chaotic situation” with patients coming in for treatment to the radiology department but patients not going up to the ward.
IV. He stated that Mrs Walker was not in the appropriate environment for post-operative monitoring .
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of porters to collect post-procedure patients
Wider context from the report “2. The Consultant Radiologist confirmed that in his opinion, the reasons for the failure to carry out the required observations were:
I. The failure of the porters to collect the patient. He stated that the failure of the porters to attend, was reported as a serious incident. He stated that this issue has still not been resolved and is an ongoing issue within the Trust .
II. The failure of nurses on the ward to take her back. (Albeit the evidence revealed that the nurses on the ward were concerned about her low blood pressure).
III. The Consultant described a “chaotic situation” with patients coming in for treatment to the radiology department but patients not going up to the ward.
IV. He stated that Mrs Walker was not in the appropriate environment for post-operative monitoring.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of ward nurses to receive post-procedure patients
Wider context from the report “2. The Consultant Radiologist confirmed that in his opinion, the reasons for the failure to carry out the required observations were:
I. The failure of the porters to collect the patient. He stated that the failure of the porters to attend, was reported as a serious incident. He stated that this issue has still not been resolved and is an ongoing issue within the Trust.
II. The failure of nurses on the ward to take her back . (Albeit the evidence revealed that the nurses on the ward were concerned about her low blood pressure).
III. The Consultant described a “chaotic situation” with patients coming in for treatment to the radiology department but patients not going up to the ward.
IV. He stated that Mrs Walker was not in the appropriate environment for post-operative monitoring.
” 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 Barking, Havering and Redbridge University Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear post-procedure clinical accountability
Wider context from the report “3. The lines of clinical accountability post-procedure, was unclear . The radiologist confirmed that Mrs Walker was no longer the responsibility of the radiology team after the procedure , as she should have gone up to the ward. The ward however were concerned with her clinical parameters and considered that she should remain with the radiologist .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations