10 Mar 2026 John Ioannou · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Failure to learn from communication failures in the care of patients with profound learning disabilities View source Failure to investigate the case under the Patient Safety Framework View source Failure to establish the aetiology and timing of a fatal infection 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
John Ioannou · 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 Ioannou, a 61-year-old non-verbal man receiving 24-hour residential care, died after a cardiac arrest on 24 June 2025 following treatment for a problem with his PEG apparatus. An autopsy identified an infection at the PEG site that spread to his small intestine and caused peritonitis. The principal concerns were that the death was not investigated under NHS England’s Patient Safety Framework, and that the cause and timing of the infection and possible communication failures were not fully explored.
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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to learn from communication failures in the care of patients with profound learning disabilities
Wider context from the report “1. The Barts Health Trust chose not to investigate this case as part of NHS England’s Patient Safety Framework. Mr Ioannou’s death ought to have been subject to such an investigation.
Firstly, despite an autopsy, the aetiology and precise timing of Mr Ioannou’s fatal infection was not fully understood. In a functioning clinical governance setting, both the possibility of the trust having missed a pre-existing infection at the time of the treatment on 23rd June 2025 or the prospect that the treatment itself caused the infection should have been explored.
Secondly, in the context of the treatment of a patient with a profound learning disability where communication failures may have contributed to poor care, a valuable learning opportunity was missed .
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate the case under the Patient Safety Framework
Wider context from the report “1. The Barts Health Trust chose not to investigate this case as part of NHS England’s Patient Safety Framework. Mr Ioannou’s death ought to have been subject to such an investigation.
Firstly, despite an autopsy, the aetiology and precise timing of Mr Ioannou’s fatal infection was not fully understood. In a functioning clinical governance setting, both the possibility of the trust having missed a pre-existing infection at the time of the treatment on 23rd June 2025 or the prospect that the treatment itself caused the infection should have been explored.
Secondly, in the context of the treatment of a patient with a profound learning disability where communication failures may have contributed to poor care, a valuable learning opportunity was missed.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish the aetiology and timing of a fatal infection
Wider context from the report “1. The Barts Health Trust chose not to investigate this case as part of NHS England’s Patient Safety Framework. Mr Ioannou’s death ought to have been subject to such an investigation.
Firstly, despite an autopsy, the aetiology and precise timing of Mr Ioannou’s fatal infection was not fully understood . In a functioning clinical governance setting, both the possibility of the trust having missed a pre-existing infection at the time of the treatment on 23rd June 2025 or the prospect that the treatment itself caused the infection should have been explored .
Secondly, in the context of the treatment of a patient with a profound learning disability where communication failures may have contributed to poor care, a valuable learning opportunity was missed.
” Open source report
26 Feb 2026 Urmila Patel · Prevention of Future Deaths report East London
View report summary
Concerns raised 9 Failure to make decisive urgent CT head scan referrals View source Failure to review preceding clinical records for relevant falls information View source Failure to undertake adequate falls risk assessments View source Failure to adequately assess the likelihood of traumatic intracranial bleeding after a fall View source Failure to record falls View source Failure to monitor and supervise patients View source Failure to produce meaningful mobility care plans View source Failure to reassess falls risk after a fall View source Failure to review warfarin prescriptions after a fall View source See 6 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. 11
Action
Deliver targeted falls-prevention education through ward teaching, safety huddles, induction and refresher training.
Stated completedThe respondent said that this action was complete when they made their response on 3 March 2026. View source
Action
Require ward rounds and multidisciplinary reviews to consider events from the preceding 24–72 hours, including weekends.
Stated completedThe respondent said that this action was complete when they made their response on 3 March 2026. View source
Action
Implement a multidisciplinary falls quality-improvement programme covering footwear, medication review and post-fall multidisciplinary review.
Stated completedThe respondent said that this action was complete when they made their response on 3 March 2026. View source
Action
Implement a mandatory post-inpatient-fall medical review bundle and standardised proforma covering neurological assessment, imaging, anticoagulation, medication review and senior escalation.
Stated completedThe respondent said that this action was complete when they made their response on 3 March 2026. View source
Action
Introduce an out-of-hours falls review protocol requiring the Duty Matron or Site Manager to review inpatient falls within two hours.
Stated completedThe respondent said that this action was complete when they made their response on 3 March 2026. View source
Action
Introduce a mandatory post-fall care bundle and checklist requiring structured assessment, neurological observations, escalation triggers and clinical documentation.
Stated completedThe respondent said that this action was complete when they made their response on 3 March 2026. View source
Action
Share case learning through medical and nursing governance forums and reinforce it through simulation training on deterioration, imaging and anticoagulation safety.
Stated completedThe respondent said that this action was complete when they made their response on 3 March 2026. View source
Action
Audit post-fall neurological observations through divisional governance and provide multidisciplinary simulation training on recognition, escalation and immediate management.
Stated completedThe respondent said that this action was complete when they made their response on 3 March 2026. View source
Action
Introduce routine ward-level audits of falls assessments and care plans, with governance escalation, tracked actions and re-audit.
Stated completedThe respondent said that this action was complete when they made their response on 3 March 2026. View source
Action
Require ward managers and nurses in charge to review new admissions each shift for completed falls assessments and care plans.
Stated completedThe respondent said that this action was complete when they made their response on 3 March 2026. View source
Action
Reinforce contemporaneous documentation and communication of inpatient falls and significant safety events during nursing and medical handovers.
Stated completedThe respondent said that this action was complete when they made their response on 3 March 2026. View source See 8 more actions
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AI-generated summary
Urmila Patel · 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
Urmila Patel, aged 78, was admitted to hospital with suspected sepsis and later fell in a ward toilet on 29 June 2025. She subsequently deteriorated and died in hospital on 7 July 2025 after a CT scan identified a significant subdural haematoma. The concerns included inadequate falls-risk assessment, mobility care planning, supervision, assessment for intracranial bleeding, timely CT referral, and review of her warfarin after the fall.
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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make decisive urgent CT head scan referrals
Wider context from the report “1. The failure of nurses on the ward to instigate an adequate falls risk assessment of Mrs Patel.
2. The failure of nursing staff on the ward to produce a meaningful care-plan for Mrs Patel’s mobility.
3. The failure of Trust staff to note a fall on 23rd June 2025 and reassess risk of falls.
4. The failure of nursing staff on the ward to monitor and supervise Mrs Patel on the afternoon of 29th June 2025.
5. The failure of Trust staff to adequately assess the likelihood of a traumatic intra-cranial bleed following the fall on 29th June 2025.
6. The failure of the duty doctor to act decisively and refer Mrs Patel for an urgent CT Head scan on 29th June 2025.
7. The failure of the duty doctor to review Mrs Patel’s warfarin prescription after the fall.
8. The failure of ward staff on the ward round on 30th June 2025 to read the clinical records from the previous day to alert them to Mrs Patel’s fall on 29th June 2025.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review preceding clinical records for relevant falls information
Wider context from the report “1. The failure of nurses on the ward to instigate an adequate falls risk assessment of Mrs Patel.
2. The failure of nursing staff on the ward to produce a meaningful care-plan for Mrs Patel’s mobility.
3. The failure of Trust staff to note a fall on 23rd June 2025 and reassess risk of falls.
4. The failure of nursing staff on the ward to monitor and supervise Mrs Patel on the afternoon of 29th June 2025.
5. The failure of Trust staff to adequately assess the likelihood of a traumatic intra-cranial bleed following the fall on 29th June 2025.
6. The failure of the duty doctor to act decisively and refer Mrs Patel for an urgent CT Head scan on 29th June 2025.
7. The failure of the duty doctor to review Mrs Patel’s warfarin prescription after the fall.
8. The failure of ward staff on the ward round on 30th June 2025 to read the clinical records from the previous day to alert them to Mrs Patel’s fall on 29th June 2025 .
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake adequate falls risk assessments
Wider context from the report “1. The failure of nurses on the ward to instigate an adequate falls risk assessment of Mrs Patel.
2. The failure of nursing staff on the ward to produce a meaningful care-plan for Mrs Patel’s mobility.
3. The failure of Trust staff to note a fall on 23rd June 2025 and reassess risk of falls.
4. The failure of nursing staff on the ward to monitor and supervise Mrs Patel on the afternoon of 29th June 2025.
5. The failure of Trust staff to adequately assess the likelihood of a traumatic intra-cranial bleed following the fall on 29th June 2025.
6. The failure of the duty doctor to act decisively and refer Mrs Patel for an urgent CT Head scan on 29th June 2025.
7. The failure of the duty doctor to review Mrs Patel’s warfarin prescription after the fall.
8. The failure of ward staff on the ward round on 30th June 2025 to read the clinical records from the previous day to alert them to Mrs Patel’s fall on 29th June 2025.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately assess the likelihood of traumatic intracranial bleeding after a fall
Wider context from the report “1. The failure of nurses on the ward to instigate an adequate falls risk assessment of Mrs Patel.
2. The failure of nursing staff on the ward to produce a meaningful care-plan for Mrs Patel’s mobility.
3. The failure of Trust staff to note a fall on 23rd June 2025 and reassess risk of falls.
4. The failure of nursing staff on the ward to monitor and supervise Mrs Patel on the afternoon of 29th June 2025.
5. The failure of Trust staff to adequately assess the likelihood of a traumatic intra-cranial bleed following the fall on 29th June 2025.
6. The failure of the duty doctor to act decisively and refer Mrs Patel for an urgent CT Head scan on 29th June 2025.
7. The failure of the duty doctor to review Mrs Patel’s warfarin prescription after the fall.
8. The failure of ward staff on the ward round on 30th June 2025 to read the clinical records from the previous day to alert them to Mrs Patel’s fall on 29th June 2025.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record falls
Wider context from the report “1. The failure of nurses on the ward to instigate an adequate falls risk assessment of Mrs Patel.
2. The failure of nursing staff on the ward to produce a meaningful care-plan for Mrs Patel’s mobility.
3. The failure of Trust staff to note a fall on 23rd June 2025 and reassess risk of falls.
4. The failure of nursing staff on the ward to monitor and supervise Mrs Patel on the afternoon of 29th June 2025.
5. The failure of Trust staff to adequately assess the likelihood of a traumatic intra-cranial bleed following the fall on 29th June 2025.
6. The failure of the duty doctor to act decisively and refer Mrs Patel for an urgent CT Head scan on 29th June 2025.
7. The failure of the duty doctor to review Mrs Patel’s warfarin prescription after the fall.
8. The failure of ward staff on the ward round on 30th June 2025 to read the clinical records from the previous day to alert them to Mrs Patel’s fall on 29th June 2025.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor and supervise patients
Wider context from the report “1. The failure of nurses on the ward to instigate an adequate falls risk assessment of Mrs Patel.
2. The failure of nursing staff on the ward to produce a meaningful care-plan for Mrs Patel’s mobility.
3. The failure of Trust staff to note a fall on 23rd June 2025 and reassess risk of falls.
4. The failure of nursing staff on the ward to monitor and supervise Mrs Patel on the afternoon of 29th June 2025.
5. The failure of Trust staff to adequately assess the likelihood of a traumatic intra-cranial bleed following the fall on 29th June 2025.
6. The failure of the duty doctor to act decisively and refer Mrs Patel for an urgent CT Head scan on 29th June 2025.
7. The failure of the duty doctor to review Mrs Patel’s warfarin prescription after the fall.
8. The failure of ward staff on the ward round on 30th June 2025 to read the clinical records from the previous day to alert them to Mrs Patel’s fall on 29th June 2025.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to produce meaningful mobility care plans
Wider context from the report “1. The failure of nurses on the ward to instigate an adequate falls risk assessment of Mrs Patel.
2. The failure of nursing staff on the ward to produce a meaningful care-plan for Mrs Patel’s mobility .
3. The failure of Trust staff to note a fall on 23rd June 2025 and reassess risk of falls.
4. The failure of nursing staff on the ward to monitor and supervise Mrs Patel on the afternoon of 29th June 2025.
5. The failure of Trust staff to adequately assess the likelihood of a traumatic intra-cranial bleed following the fall on 29th June 2025.
6. The failure of the duty doctor to act decisively and refer Mrs Patel for an urgent CT Head scan on 29th June 2025.
7. The failure of the duty doctor to review Mrs Patel’s warfarin prescription after the fall.
8. The failure of ward staff on the ward round on 30th June 2025 to read the clinical records from the previous day to alert them to Mrs Patel’s fall on 29th June 2025.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to reassess falls risk after a fall
Wider context from the report “1. The failure of nurses on the ward to instigate an adequate falls risk assessment of Mrs Patel.
2. The failure of nursing staff on the ward to produce a meaningful care-plan for Mrs Patel’s mobility.
3. The failure of Trust staff to note a fall on 23rd June 2025 and reassess risk of falls .
4. The failure of nursing staff on the ward to monitor and supervise Mrs Patel on the afternoon of 29th June 2025.
5. The failure of Trust staff to adequately assess the likelihood of a traumatic intra-cranial bleed following the fall on 29th June 2025.
6. The failure of the duty doctor to act decisively and refer Mrs Patel for an urgent CT Head scan on 29th June 2025.
7. The failure of the duty doctor to review Mrs Patel’s warfarin prescription after the fall.
8. The failure of ward staff on the ward round on 30th June 2025 to read the clinical records from the previous day to alert them to Mrs Patel’s fall on 29th June 2025.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review warfarin prescriptions after a fall
Wider context from the report “1. The failure of nurses on the ward to instigate an adequate falls risk assessment of Mrs Patel.
2. The failure of nursing staff on the ward to produce a meaningful care-plan for Mrs Patel’s mobility.
3. The failure of Trust staff to note a fall on 23rd June 2025 and reassess risk of falls.
4. The failure of nursing staff on the ward to monitor and supervise Mrs Patel on the afternoon of 29th June 2025.
5. The failure of Trust staff to adequately assess the likelihood of a traumatic intra-cranial bleed following the fall on 29th June 2025.
6. The failure of the duty doctor to act decisively and refer Mrs Patel for an urgent CT Head scan on 29th June 2025.
7. The failure of the duty doctor to review Mrs Patel’s warfarin prescription after the fall .
8. The failure of ward staff on the ward round on 30th June 2025 to read the clinical records from the previous day to alert them to Mrs Patel’s fall on 29th June 2025.
” 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 Deliver targeted falls-prevention education through ward teaching, safety huddles, induction and refresher training.
Verbatim wording from the response “Targeted education has been delivered to nursing staff, focusing on the timely completion of falls risk assessments on admission, recognition of dynamic risk, and the importance of translating assessed risk into clear and practical care plans. This has been reinforced through ward-based teaching, safety huddles, and incorporation into local induction and refresher training.” Source location Response from Barts Health 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 Require ward rounds and multidisciplinary reviews to consider events from the preceding 24–72 hours, including weekends.
Verbatim wording from the response “Ward teams have been reminded that ward rounds and multidisciplinary reviews must include active consideration of events from the preceding 24–72 hours, including weekends.” Source location Response from Barts Health 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 Implement a multidisciplinary falls quality-improvement programme covering footwear, medication review and post-fall multidisciplinary review.
Verbatim wording from the response “Falls prevention has also been strengthened through a multidisciplinary quality improvement programme, recognising the contribution of nursing, medical, therapy, and pharmacy teams. This includes initiatives focused on appropriate footwear, structured medication review (including medicines associated with increased falls risk), and consistent post-fall multidisciplinary review.
To support assurance, a ward-level falls audit programme commenced on 2 February 2026, with the most recent audit completed on 14 April 2026. Early findings demonstrate high compliance with falls risk assessment (97.2%), improved initiation of falls care plans (83.3%), improved completion of lying and standing blood pressure (78%), and timely medical review following falls. These findings are reviewed through ward and divisional governance processes to support sustained improvement.” Source location Response from Barts Health 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 Implement a mandatory post-inpatient-fall medical review bundle and standardised proforma covering neurological assessment, imaging, anticoagulation, medication review and senior escalation.
Verbatim wording from the response “A mandatory post-inpatient fall medical review care bundle has been implemented, supported by a standardised proforma. This provides a structured framework for clinical assessment and decision-making following a fall.” Source location Response from Barts Health 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 an out-of-hours falls review protocol requiring the Duty Matron or Site Manager to review inpatient falls within two hours.
Verbatim wording from the response “Senior oversight has been enhanced through the introduction of an out-of-hours falls review protocol, requiring the Duty Matron or Site Manager to review all inpatient falls within two hours, providing assurance that appropriate actions and escalation have occurred.” Source location Response from Barts Health 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 mandatory post-fall care bundle and checklist requiring structured assessment, neurological observations, escalation triggers and clinical documentation.
Verbatim wording from the response “A mandatory post-fall care bundle and checklist has been introduced for all inpatient falls. This ensures that each fall is managed as a clinical event requiring structured assessment and response, aligned to the Patient Safety Incident Response Framework.” Source location Response from Barts Health 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 Share case learning through medical and nursing governance forums and reinforce it through simulation training on deterioration, imaging and anticoagulation safety.
Verbatim wording from the response “Learning from this case has been shared through medical and nursing governance forums and reinforced through simulation-based training focusing on deterioration, imaging decisions, and anticoagulation safety.” Source location Response from Barts Health 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 Audit post-fall neurological observations through divisional governance and provide multidisciplinary simulation training on recognition, escalation and immediate management.
Verbatim wording from the response “Monitoring reliability has been strengthened through regular audit of post-fall neurological observations, with findings reviewed through divisional governance structures. In addition, multidisciplinary simulation training has been introduced, using scenarios such as anticoagulated patients and neurological deterioration, to reinforce recognition of risk, escalation, and immediate management.” Source location Response from Barts Health 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 routine ward-level audits of falls assessments and care plans, with governance escalation, tracked actions and re-audit.
Verbatim wording from the response “A programme of routine audit has been introduced to review both completion and quality of falls risk assessments and care plans. Findings are reviewed at ward level and escalated through Divisional Governance where required, with actions agreed, tracked, and re-audited.” Source location Response from Barts Health 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 Require ward managers and nurses in charge to review new admissions each shift for completed falls assessments and care plans.
Verbatim wording from the response “Accountability has been strengthened through clearer expectations of ward leadership. Ward managers and nurses in charge are now required to review new admissions each shift to confirm that falls risk assessments and associated care plans have been completed, with prompt action taken where gaps are identified.” Source location Response from Barts Health 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 Reinforce contemporaneous documentation and communication of inpatient falls and significant safety events during nursing and medical handovers.
Verbatim wording from the response “Actions taken
The Trust has reinforced expectations that all inpatient falls and significant safety events are documented contemporaneously and clearly communicated during both nursing and medical handover.” Source location Response from Barts Health NHS Trust
Open published response
9 Dec 2025 Urielle Mayila Kuyenga · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Breakdown of communication about responsibility for penicillin prescription and dispensation View source Failure of clinicians to identify Sickle Cell Disease from available clinical records 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
Urielle Mayila Kuyenga · 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
Urielle Mayila Kuyenga, a four-year-old girl with sickle-cell disease, died in hospital on 4 December 2023 from sepsis resulting from bacterial pneumonia. The report identifies failures to ensure administration of prescribed prophylactic penicillin and failures by doctors to identify her sickle-cell diagnosis during three presentations for respiratory infection as contributory factors.
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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Breakdown of communication about responsibility for penicillin prescription and dispensation
Wider context from the report “1. As a patient with Sickle Cell Disease, Urielle was prescribed prophylactic penicillin to mitigate the risk of her developing fatal symptoms arising from typical respiratory infections. Urielle’s mother chose not to collect those prescriptions and administer penicillin to Urielle. While specialist doctors believed that her GP was monitoring the prescription and dispensation of the penicillin, whilst Urielle’s GP was misled by Urielle’s mother that the hospital were dispensing the medication directly. The breakdown of communication means that Urielle was left unprotected from opportunistic infection which caused this avoidable 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of clinicians to identify Sickle Cell Disease from available clinical records
Wider context from the report “2. In the weeks prior to her death Urielle’s mother presented her daughter to three separate GPs about a respiratory infection. On each of these three attendances the attending clinician was ignorant of Urielle’s Sickle Cell diagnosis. The reasons for these lapses were, firstly Urielle’s mother did not inform the doctor of the fact and, second, that the doctors did not adequately read the clinical records available to them .
” Open source report
29 Sep 2025 Mohammad Ali Asghar · Prevention of Future Deaths report East London
View report summary
Concerns raised 4 Lack of senior governance staff understanding of guidance on patient safety investigation triggers View source Failure to undertake a patient safety framework investigation when concerns and review triggers arise View source Failure of patient safety governance to identify incidents requiring investigation View source Failure of patient safety governance to reflect upon and remediate sub-optimal practice View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mohammad Ali Asghar · 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
Mohammad Ali Asghar was admitted to hospital with worsening shortness of breath and fluid overload, and later suffered a cardiac arrest after catheter removal following haematuria and clots. The principal concerns were failures in Trust governance and incident-reporting processes, including the failure to identify and investigate the case through the Patient Safety Framework despite concerns about an iatrogenic injury and a court direction for review.
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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of senior governance staff understanding of guidance on patient safety investigation triggers
Wider context from the report “3. Correspondence received from the Trust sent three months after the inquest that seeks to explain why a PSRF investigation was not undertaken in this case betrays the fact that senior governance staff at the Trust still do not understand NHS England guidance on what should trigger a patient safety investigation .
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake a patient safety framework investigation when concerns and review triggers arise
Wider context from the report “2. Despite concerns being raised by a medical examiner, a coroner’s court finding that an iatrogenic injury was contributory to death, and an express direction from this court for the case to be reviewed, no patient safety framework investigation has occurred .
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of patient safety governance to identify incidents requiring investigation
Wider context from the report “1. A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework . This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice. In this case the trust’s Datix incident reporting system, morbidity and mortality meeting process and PSIRF procedure were inadequate .
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of patient safety governance to reflect upon and remediate sub-optimal practice
Wider context from the report “1. A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice . In this case the trust’s Datix incident reporting system, morbidity and mortality meeting process and PSIRF procedure were inadequate.
” 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 an independent review of governance and PSIRM decision-making for PSIRF learning responses, including PSII criteria and thresholds.
Verbatim wording from the response “To support this, Barts Health is in the process of commissioning an Independent Review of our governance processes with comprehensive terms of reference which will include review of our decision-making at Patient Safety Incident Review Meeting (PSIRM) relating to the learning responses under PSIRF. This review will examine the criteria and thresholds used to determine when a PSII or alternative learning response is required, ensuring these are clearly defined, consistently applied, and responsive to emerging information or stakeholder concerns.” Source location Response from Barts Health NHS Foundation Trust
Open published response
23 Sep 2025 Tony Buengo Jackson · Prevention of Future Deaths report East London
View report summary
Concerns raised 6 Unavailability of notes for the 24th November admission View source Failure to detect iatrogenic injury despite clinical assessment and investigation View source Failure of governance processes to remediate sub-optimal practice View source Poor recording of best interest decisions, PEG insertion and subsequent treatment View source Failure to identify incidents requiring investigation through the Patient Safety Framework View source Failure of governance processes to reflect upon sub-optimal practice 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
Tony Buengo Jackson · 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
Tony Buengo-Jackson, who had progressive multiple sclerosis and lived in a nursing home, died after a PEG tube inserted on 19 November 2024 passed through his transverse colon, causing bowel perforation, peritonitis and sepsis. The report raises concerns that the injury was not detected until 3 December despite an earlier admission, CT scan and surgical consultation, and that poor records and inadequate Trust governance impeded investigation and learning.
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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of notes for the 24th November admission
Wider context from the report “3. The Trust could not provide notes of the 24th November admission .
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to detect iatrogenic injury despite clinical assessment and investigation
Wider context from the report “1. A fatal iatrogenic injury caused to Tony Buengo-Jackson on 19th November 2024 went undetected until 3rd December 2024 , despite admission, CT scan and surgical consult on 24th November 2024 .
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of governance processes to remediate sub-optimal practice
Wider context from the report “4. A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice in this case the trust’s Datix incident reporting system, morbidity and mortality meeting process and PSIRF procedure were inadequate .
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Poor recording of best interest decisions, PEG insertion and subsequent treatment
Wider context from the report “2. Records of, best interest decisions, the PEG insertion and subsequent treatment were so poor as to impede the court’s 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify incidents requiring investigation through the Patient Safety Framework
Wider context from the report “4. A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework . This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify , reflect upon, and remediate sub-optimal practice in this case the trust’s Datix incident reporting system, morbidity and mortality meeting process and PSIRF procedure were inadequate.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of governance processes to reflect upon sub-optimal practice
Wider context from the report “4. A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon , and remediate sub-optimal practice in this case the trust’s Datix incident reporting system, morbidity and mortality meeting process and PSIRF procedure were inadequate .
” 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 Issue Trust-wide communication requiring significant or unexpected complications to be recorded on Datix for PSIRF consideration.
Verbatim wording from the response “• A Trust-wide communication was issued in October 2025 reminding staff that all significant or unexpected complications, including recognised but serious procedural injuries, must be recorded on Datix for PSIRF consideration.” Source location Response from Barts Health 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 Expand the Endoscopy Governance Meeting into a bi-monthly joint Surgery and Gastroenterology forum with governance and nursing representation.
Verbatim wording from the response “• The Endoscopy Governance Meeting is being expanded to include the surgical directorate as a bi-monthly joint forum agenda (within the Gastroenterology Governance Forum) between Surgery and Gastroenterology, with governance and nursing representation, to support shared learning from endoscopy-related adverse events.” Source location Response from Barts Health 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 Embed governance representation within Surgical and Gastroenterology Morbidity and Mortality meetings.
Verbatim wording from the response “• Governance presence is now embedded within Surgical and Gastroenterology M&M meetings to ensure improved linkage between M&M learning, Datix reporting, and PSIRF oversight.” Source location Response from Barts Health 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 Review all deaths proceeding to Coroner’s inquest at PSERM to ensure Datix capture, multidisciplinary review and an assigned learning response.
Verbatim wording from the response “• All deaths that proceed to Coroner’s inquest are now reviewed at the Patient Safety Event Response Meeting (PSERM) to ensure:
o The event is captured on Datix,” Source location Response from Barts Health 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 Reissue documentation guidance to consultants and trainees and disseminate it through governance meetings and resident doctor teaching.
Verbatim wording from the response “• Guidance has been re-issued to consultants and trainees regarding documentation standards for capacity assessments and best-interest decisions. This has been discussed in divisional Clinical Governance meetings and included in Resident Doctor teaching.” Source location Response from Barts Health 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 Roll out e-consent in endoscopy with sections for consent form 4 and best-interest discussions.
Verbatim wording from the response “• E-consent has been rolled out in endoscopy in the last 12 months and includes a detailed section for consent form 4 and best interests discussions. Currently only a limited number of clinicians have access to this system.” Source location Response from Barts Health 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 Reinforce requirements for clearly documenting best-interest discussions, including participants, reasoning, risks, benefits and outcomes.
Verbatim wording from the response “• The Trust has reinforced the requirement that all best-interest discussions are documented in the patient record, clearly recording:
o who was present,
o the clinical reasoning and evidence considered,
o risks and benefits discussed,
o and the agreed outcome.” Source location Response from Barts Health 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 Support divisions to improve recording of Morbidity and Mortality discussions, including use of Microsoft Copilot to capture decisions, themes and actions.
Verbatim wording from the response “• The Trust is also strengthening the recording of Morbidity and Mortality (M&M) discussions across all divisions. Following a review of M&M processes at the December Quality and Safety Committee, divisions will be supported to embed improved documentation standards and the use of Microsoft Copilot to capture decisions, themes and actions. This will ensure that learning identified at M&M is consistently recorded, traceable, and easily retrievable for follow-up through PSERM and divisional governance structures.” Source location Response from Barts Health 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 Review the case through the Surgical Division’s Morbidity and Mortality process and share the learning.
Verbatim wording from the response “• The case has been reviewed through the Surgical Division’s Morbidity and Mortality (M&M) process and learning shared.” Source location Response from Barts Health 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 Discuss standardising e-consent and expanding Concentric Platform access to improve electronic-record integration and reduce paper consent documentation.
Verbatim wording from the response “• E-consent has been rolled out in endoscopy in the last 12 months and includes a detailed section for consent form 4 and best interests discussions. Currently only a limited number of clinicians have access to this system.” Source location Response from Barts Health 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 consultant surgeon’s CT interpretation was a reasonable differential diagnosis given the evidence available at the time.
Verbatim wording from the response “Our review confirmed that the consultant surgeon’s interpretation of the CT scan at that time represented a reasonable differential diagnosis given the available evidence. However, the rationale for this interpretation was not fully documented, limiting retrospective understanding of the decision.” Source location Response from Barts Health NHS Trust
Open published response
16 Jun 2025 Mrs Norma Faye Campbell · Prevention of Future Deaths report East London
View report summary
Concerns raised 9 Overcrowding in A&E View source Inadequate medical facilities in A&E View source Insufficient numbers of resuscitation beds View source Inadequate staffing in A&E View source Lack of monitoring equipment in the majors area of A&E View source Failure to provide appropriate care for patients requiring monitoring in A&E corridors View source Failure of the Critical Care Outreach Team to attend A&E for deteriorating patients View source Insufficient staffing in the majors area of A&E View source Lack of an electronic observation system for automatically escalating high NEWS scores in A&E View source See 6 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
Mrs Norma Faye Campbell · 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 Norma Faye Campbell attended Whipps Cross Hospital emergency department on 13 January 2024 with clear signs of sepsis and died there in the early hours of 14 January 2024 after suffering a cardiac arrest. The report identifies delays and omissions in sepsis treatment, monitoring, fluid resuscitation and escalation of care. It also raises concerns about overcrowding, inadequate staffing and facilities, insufficient resuscitation beds, lack of electronic observations and the absence of Critical Care Outreach Team support in the emergency department.
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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Overcrowding in A&E
Wider context from the report “1. The inquest heard that the A&E department at Whipps Cross Hospital often has inadequate staffing and medical facilities to address the patient numbers and acuity. The inquest heard that overcrowding in A&E is a national concern .
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate medical facilities in A&E
Wider context from the report “1. The inquest heard that the A&E department at Whipps Cross Hospital often has inadequate staffing and medical facilities to address the patient numbers and acuity . The inquest heard that overcrowding in A&E is a national concern.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient numbers of resuscitation beds
Wider context from the report “3. There are often insufficient numbers of resuscitation beds . Patients who require a resuscitation area level of care are often directed to the majors area of A&E. The majors area lacks the levels of staffing and lacks the monitoring equipment required to treat this cohort of patients. In the absence of increased numbers of resuscitation beds, a system for continuous monitoring of observations in majors would significantly improve patient care.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate staffing in A&E
Wider context from the report “1. The inquest heard that the A&E department at Whipps Cross Hospital often has inadequate staffing and medical facilities to address the patient numbers and acuity. The inquest heard that overcrowding in A&E is a national concern.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of monitoring equipment in the majors area of A&E
Wider context from the report “3. There are often insufficient numbers of resuscitation beds. Patients who require a resuscitation area level of care are often directed to the majors area of A&E. The majors area lacks the levels of staffing and lacks the monitoring equipment required to treat this cohort of patients . In the absence of increased numbers of resuscitation beds, a system for continuous monitoring of observations in majors would significantly improve patient care.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate care for patients requiring monitoring in A&E corridors
Wider context from the report “2. The inquest heard that it is not uncommon to find patients in corridors when they need to be monitored . On the 13 January 2024 there were more than 25 patients in the corridors. They were not receiving an appropriate level of care .
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the Critical Care Outreach Team to attend A&E for deteriorating patients
Wider context from the report “5. The Critical Care Outreach Team (CCOT) do not currently attend A&E for deteriorating patients . The overcrowding and lack of resourcing in A&E highlights the need for the CCOT to provide support to A&E patients as well as patients on the ward.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing in the majors area of A&E
Wider context from the report “3. There are often insufficient numbers of resuscitation beds. Patients who require a resuscitation area level of care are often directed to the majors area of A&E. The majors area lacks the levels of staffing and lacks the monitoring equipment required to treat this cohort of patients. In the absence of increased numbers of resuscitation beds, a system for continuous monitoring of observations in majors would significantly improve patient care.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an electronic observation system for automatically escalating high NEWS scores in A&E
Wider context from the report “4. There is no electronic observation system in place within the A&E department of Whipps Cross Hospital (such as Live Note). Patients presenting with high NEWS scores are not therefore automatically brought to the attention of clinical supervisors .
” 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 Operate a weekly urgent and emergency care committee addressing Emergency Department overcrowding, reconfiguration and exit-block pressures.
Verbatim wording from the response “As part of the ongoing review of the Urgent and Emergency Care pathway at Whipps Cross Hospital, a weekly committee chaired by ████████, Chief Executive at Whipps Cross Hospital commenced in February 2025 to look at the issues in the Emergency Department and our inpatient wards. This committee addresses the issues around overcrowding, the reconfiguration of the department and how the hospital will tackle “exit block” from the Emergency Department which are referenced by the concerns you have raised. Whilst this committee looks at the overall issues (with quality improvement workstreams looking at different areas) the Trust also acknowledges the specific concerns that we have addressed below.” Source location Response from Barts Health NHS Foundation 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 Continue work to reduce hospital length of stay and associated Emergency Department overcrowding.
Verbatim wording from the response “Looking at the Summary Acute Medicine Indicator Table (SAMIT) data for April 2025 compared to April 2024 the average length of stay in the hospital has dropped from 13.4 days to 10.9 days and we are committed to work to continue to reduce this and thus reduce overcrowding in the Emergency Department.” Source location Response from Barts Health NHS Foundation 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 Increase Emergency Department medical staffing to the approved establishment, completing recruitment of resident doctors and consultant grades.
Verbatim wording from the response “In May 2024, the Hospital Executive Board at Whipps Cross Hospital approved the increase in whole time equivalent (WTE) medical staff from 43 WTE to 63 WTE. This was an increase in 1.1 WTE consultants, 10 WTE Tier A (registrar) grade residents and 5 additional Paediatric Emergency residents (4 at registrar grade and 1 at senior house officer grade). In addition, locum shifts equivalent to 5 WTE were also approved as part of the staffing to ensure that the department was appropriately always staffed. Recruitment has been ongoing since June 2024 and for August 2025, the agreed establishment will be fully recruited for resident doctors with successful interviews for the consultant grades on 17th July 2025. This brought Whipps Cross into line with the other Emergency Departments within Barts Health for medical staffing.” Source location Response from Barts Health NHS Foundation 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 Implement electronic observations and Early Warning Score visibility across Emergency Department clinical areas using the upgraded patient record and observation machines.
Verbatim wording from the response “In 2024 the Trust upgraded the electronic patient record in the Emergency Department to the “Launchpoint” system provided by Oracle and purchased in May 2024 an additional 49 observations machines that directly relay clinical observations to the electronic patient record.” Source location Response from Barts Health NHS Foundation 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 Promote mandatory consultant-to-consultant handovers to support timely decisions in the resuscitation area.
Verbatim wording from the response “Additionally, enforcing internal professional standards, such as mandatory consultant-to-consultant handovers, will support faster decision-making and reduce unnecessary delays in the resus area is something that the senior leadership team within the hospital is actively” Source location Response from Barts Health NHS Foundation 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 a new centrally located resuscitation area near the assessment zones.
Verbatim wording from the response “We have planned infrastructural improvements, including a new centrally located resuscitation area near assessment zones, which is expected to enhance flow.” Source location Response from Barts Health NHS Foundation 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 Recruit to the approved increase of 10.5 whole-time-equivalent Emergency Department nursing posts.
Verbatim wording from the response “For nursing staff, the Hospital Executive Board has approved an increase in 10.5 WTE nursing staff in line with the Safer Nursing Care Tool review of staffing and is currently in the process of recruiting to these posts.” Source location Response from Barts Health NHS Foundation 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 Implement quality-improvement, discharge and cross-organisational oversight workstreams to reduce inpatient delays and Emergency Department exit block.
Verbatim wording from the response “There is also ongoing work across the hospital to reduce length of stay on the wards and prevent “exit block” from the Emergency Department. This includes a Quality Improvement programme around the use of electronic whiteboards, a dedicated workstream about discharge and a regular systems oversight meeting that looks at how health and social care organisations across Waltham Forest and Redbridge can work together to reduce delays in discharge.” Source location Response from Barts Health NHS Foundation 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 Reconfigure the Emergency Department into a dedicated 14-trolley assessment area and remove existing corridor space.
Verbatim wording from the response “The Trust has committed to reconfiguring the Emergency Department at Whipps Cross Hospital. Work to do this has commenced and is due to be fully completed in March 2026. This will reconfigure the current Emergency Assessment area from 4 cubicles and some corridor space to a dedicated 14 trolley assessment area (this work is due to be completed by January 2026) and remove the current corridor space.” Source location Response from Barts Health NHS Foundation 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 Open and operate a 17-bed temporary escalation space with dedicated nursing and medical staff to relieve Emergency Department capacity pressures.
Verbatim wording from the response “Where we do have days that there is overcrowding within the Emergency Department, additional nurses are redeployed to provide “fundamentals of care” and care for the patients waiting to be admitted to the hospital. In winter 2024/2025 an additional 17 bedded “temporary escalation space” was opened with dedicated nursing and medical staff next to the Emergency Department to care for patients who required admission to hospital and had already commenced treatment to free up space within the Emergency Department for patients who were requiring assessment.” Source location Response from Barts Health NHS Foundation 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 A critical care in-reach registrar with consultant intensivist access provides responsive Emergency Department support, although it does not replace full CCOT presence.
Verbatim wording from the response “We would like to acknowledge and address the concern raised about the absence of a formal CCOT presence in the Emergency Department. CCOT do not currently have the skill set or resource to review acutely unwell and undifferentiated patients within the emergency department. An extended period of training would be required which will need to be determined by local service needs and referenced to outreach services that have successfully implemented this. However, we recognise the importance of timely critical care input and have alternative arrangements to ensure support is available when needed. The current pathway is that the critical care in-reach registrar, who is assigned for reviewing patients outside of intensive care unit, is available to attend the ED, this registrar has access to a consultant intensivist at any” Source location Response from Barts Health NHS Foundation 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 CCOT cannot currently review acutely unwell, undifferentiated Emergency Department patients because it lacks the required skills and resources.
Verbatim wording from the response “We would like to acknowledge and address the concern raised about the absence of a formal CCOT presence in the Emergency Department. CCOT do not currently have the skill set or resource to review acutely unwell and undifferentiated patients within the emergency department. An extended period of training would be required which will need to be determined by local service needs and referenced to outreach services that have successfully implemented this. However, we recognise the importance of timely critical care input and have alternative arrangements to ensure support is available when needed. The current pathway is that the critical care in-reach registrar, who is assigned for reviewing patients outside of intensive care unit, is available to attend the ED, this registrar has access to a consultant intensivist at any” Source location Response from Barts Health NHS Foundation Trust
Open published response
27 May 2025 Abdirahman Afrah · Prevention of Future Deaths report East London
View report summary
Concerns raised 7 Failure to send relevant results and discharge summaries to the GP in time for appointments View source Failure to commence appropriate investigations at an early stage View source Excessive waiting times for assessment in Majors A&E View source Failure to directly discuss the need to return to A&E with a responsible parent of a young patient View source Failure to provide timely medical triage of Majors patients at risk of clinical decline View source Failure to ensure doctors have complete relevant clinical information when calling patients who have left A&E View source Failure to clearly communicate the risk of not returning to hospital View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Abdirahman Afrah · 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
Abdirahman Afrah developed severe chest pain and attended A&E, but left without being seen by a doctor after a prolonged wait. He later collapsed at home and died in hospital on 4 June 2024 from bleeding caused by a pulmonary vascular malformation. The concerns included prolonged A&E waits, lack of timely medical triage, unclear communication about the urgency of returning to hospital, failure to discuss this directly with a responsible parent, and failure to send results to his GP in time.
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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to send relevant results and discharge summaries to the GP in time for appointments
Wider context from the report “5. When Abdirahman stated that he would be seeing his GP later that afternoon, he asked for the relevant results to be sent to the GP. Neither the results, nor the discharge summary were sent to the GP in time for the appointment . The inquest heard that the A&E doctor did not know how to share such information with the GP .
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to commence appropriate investigations at an early stage
Wider context from the report “2. There was no timely triage of Majors patients by the medical team, to ensure that those with the greatest potential of clinical decline are picked up quickly and appropriate investigations commenced at an early stage . Without such frontloading of care , patients like Abdirahman who might compensate right up to the point of collapse, might be missed again.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Excessive waiting times for assessment in Majors A&E
Wider context from the report “1. The inquest heard that waiting times to be seen in Majors A&E at Newham University Hospital could sometimes be between 9 to 14 hours . Many patients are unable to tolerate such long waits and leave the department before being seen .
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to directly discuss the need to return to A&E with a responsible parent of a young patient
Wider context from the report “4. Abdirahman was 17 years old. He declined to return to A&E. There was no direct discussion with a responsible parent about the need to return to A&E .
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely medical triage of Majors patients at risk of clinical decline
Wider context from the report “2. There was no timely triage of Majors patients by the medical team , to ensure that those with the greatest potential of clinical decline are picked up quickly and appropriate investigations commenced at an early stage. Without such frontloading of care, patients like Abdirahman who might compensate right up to the point of collapse, might be missed again.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure doctors have complete relevant clinical information when calling patients who have left A&E
Wider context from the report “3. When the doctor called Abdirahman the following afternoon, she did not have all of the relevant clinical information to hand . She was not aware of the compensated metabolic acidosis . It is unlikely that she advised Abdirahman of the importance of returning to the hospital. It is foreseeable that patients may be reticent to return to A&E, because of the lengthy waits, so doctors making the call to patients who have left, should be fully informed about the clinical condition and risks . The risk of not returning should be made very clear.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly communicate the risk of not returning to hospital
Wider context from the report “3. When the doctor called Abdirahman the following afternoon, she did not have all of the relevant clinical information to hand. She was not aware of the compensated metabolic acidosis. It is unlikely that she advised Abdirahman of the importance of returning to the hospital. It is foreseeable that patients may be reticent to return to A&E, because of the lengthy waits, so doctors making the call to patients who have left, should be fully informed about the clinical condition and risks. The risk of not returning should be made very clear .
” 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 Train regular locum doctors in rapid assessment and treatment.
Verbatim wording from the response “Since August 2024, enhanced RAT training has been added to the induction of all resident doctors above foundation level and there is an active program to train all regular locum doctors in this process. This has increased our capacity to front-load tests and investigations throughout the day and night.” Source location 2025-0245- Response from Barts Health NHS Foundation 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 Provide junior doctors with dedicated administration time to check results and communicate them to patients and GP practices.
Verbatim wording from the response “Since August 2024 we introduced specific administration time for junior doctors in ED to check results. During this process all resident doctors have been using Accurx to contact patients and GP practices and thus the use of this form of communication has increased significantly.” Source location 2025-0245- Response from Barts Health NHS Foundation 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 Escalate every under-18 patient leaving without treatment to a senior clinician in real time.
Verbatim wording from the response “We have included a section in our current staff safety bulletin that any patients under 18 who have left without treatment must be escalated to a senior clinician in real time so that the appropriate response can be decided upon and implemented.” Source location 2025-0245- Response from Barts Health NHS Foundation 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 Expand Same Day Emergency Care capacity by enlarging space, merging clinical teams and increasing staffing.
Verbatim wording from the response “Over the past 12 months we have expanded our physical space in the Same Day Emergency Care (SDEC) area. We have also merged our ambulatory medical and emergency medical clinical teams working in this area, with additional increase in clinical staffing numbers. This has allowed suitable patients to be directed to the most suitable clinical area and as a result this has reduced waiting times in the emergency department and improved patient experience. For example, patients presenting with chest pain follow one of the key pathways that can be assessed on SDEC, as well as easing the pressure on emergency patients in the main department.” Source location 2025-0245- Response from Barts Health 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 a dedicated Fast Lane for walk-in emergency patient assessment and treatment.
Verbatim wording from the response “Since October 2024 we have introduced a new ‘Fast Lane’ for assessment and treatment of walk-in emergency patients. The provision of an area with consultation rooms and dedicated ED doctors has resulted in decreased waiting times for this group of patients and improved performance against the 4-hour target for non-admitted emergency patients from 50 to 65%.” Source location 2025-0245- Response from Barts Health 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 Use customised acuity flags to prioritise patients with specified clinical, infectious, vulnerability or mental-health risks.
Verbatim wording from the response “Acuity flags and concerns. We have introduced a customised acuity rating system for patients falling into different risk groups to draw attention and give priority. These are those who have infectious diseases, those who are vulnerable (through physical or other disability, hearing or communication issues), mental health presentations and those who have clinical concerns requiring prompt response (sickle cell, crisis cancer with immunosuppression, sepsis).” Source location 2025-0245- Response from Barts Health 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 Use electronic vital-sign frequency and red-heart alerts to prompt repeat observations and urgent attention.
Verbatim wording from the response “In the last 12 months we have implemented several electronic tools that provide at a glance prompts to senior medical and nursing staff. These are designed to draw attention to patients who need immediate action or should be seen sooner.” Source location 2025-0245- Response from Barts Health 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 Use hospital-wide action cards to manage prolonged emergency department waits and escalate workload pressures.
Verbatim wording from the response “Recognising that a functioning ED and manageable waiting times depend on a whole hospital response, ‘action cards’ have been created which give actions to ED nursing and medical teams, hospital site management and specialty teams to manage long waits in ED. Actions include direct referral to specialty teams to see patients, accessing escalation areas, triggering contact with Trust managers and directors to manage workload across the Group.” Source location 2025-0245- Response from Barts Health 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 Increase senior resident staffing to provide greater senior oversight and earlier decisions in the emergency department.
Verbatim wording from the response “We have successfully recruited to all of our consultant vacancies in the last 6 months and will have a significant increase in senior residents managing the department from August 2025. This increase in senior decision makers will enhance the safety in the department overall, with senior oversight over the queue and earlier definitive decision making in the patient journey with a resultant reduction in waiting times.” Source location 2025-0245- Response from Barts Health 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 Add enhanced rapid assessment training to resident doctor induction.
Verbatim wording from the response “Since August 2024, enhanced RAT training has been added to the induction of all resident doctors above foundation level and there is an active program to train all regular locum doctors in this process. This has increased our capacity to front-load tests and investigations throughout the day and night.” Source location 2025-0245- Response from Barts Health 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 and formalise the Left Without Treatment policy covering patient risk advice, under-18 safeguards and urgent clinical information sharing.
Verbatim wording from the response “The responses will be delivered in an updated ‘Left Without Treatment’ (LWOT) policy (drafted and waiting formal review and stakeholder approval) and an immediate safety bulletin which will be actively shared to all staff groups in the Emergency Department. This will be shared electronically, and daily at in-person handovers to reach as many staff as possible to effect immediate change in practice. More detail is included in each section.” Source location 2025-0245- Response from Barts Health 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 Improve initial self-presenting patient assessment through a quality improvement project, assessment pathways and nursing education.
Verbatim wording from the response “There is an active quality improvement project ongoing which is aimed at improving processes for initial assessment of patients self-presenting to the emergency department. The aim of this project is to decrease initial assessment waiting times. In addition, there is a focused area for high-risk patients where there is increased availability of the RAT Dr to respond to queries, review patients, request imaging and start treatments. The project includes introducing easy to follow assessment” Source location 2025-0245- Response from Barts Health 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 A blanket rule requiring disclosure of adolescents’ attendance to parents may not serve their best interests.
Verbatim wording from the response “We recognise that those under the age of 18 are children by law and, where appropriate, a responsible adult or person with parental responsibility is likely to need to be contacted. However, adolescents are special group that deserve due consideration. It would not be appropriate to make a blanket rule to disclose information about attendance to a parent or guardian when in some cases this may not be in the best interests of the adolescent.” Source location 2025-0245- Response from Barts Health NHS Foundation Trust
Open published response
12 May 2025 Kenneth Foster · Prevention of Future Deaths report East London
View report summary
Concerns raised 1 Failure of governance and safety-review processes to identify, investigate, reflect upon, and remediate sub-optimal practice View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kenneth Foster · 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
Kenneth Foster, who had epilepsy following a traumatic brain injury in 2012, was admitted to hospital after prolonged seizure activity in September 2024. After interruption of clobazam administration following removal of his naso-gastric tube, his seizures resumed; he was later diagnosed with aspiration pneumonia, which led to his death. The report identified concerns about failures in governance and inadequate incident reporting, morbidity and mortality processes, and Patient Safety Incident Response Framework procedures.
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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of governance and safety-review processes to identify, investigate, reflect upon, and remediate sub-optimal practice
Wider context from the report “A. A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice.
In this case the trust’s Datix incident reporting system, morbidity and mortality meeting process and PSIRF procedure were inadequate.
” 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 Contact families during PSIRM reviews so their concerns inform the review and decision on the level of investigation required.
Verbatim wording from the response “As part of the learning from this PFD, the Whipps Cross Hospital Senior Leadership Team will ensure that families are contacted as part of the Patient Safety Incident Review Meeting (PSIRM) process to ensure that a more robust review is undertaken. Taking account of family concerns should be a key aspect to inform decision making around the level of investigation required. This action will also ensure reviews include the views of the patient’s family, in line with Patient Safety Incident Response Framework (PSIRF) compassionate engagement principles.” Source location 2025-0231-Response from Barts Health 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 Report each new inquest in Datix, present it at PSIRM, and expedite any outstanding M&M review to inform the required learning response.
Verbatim wording from the response “Since December 2024, at Whipps Cross Hospital, each new inquest opened is reported via the incident reporting system (Datix). The cases are presented at the Patient Safety Incident Response Meeting (PSIRM) and where a Mortality and Morbidity Meeting (M&M) has not yet been held, arrangements are made to expedite this process to inform decision making around the type of learning response required in accordance with the Patient Safety Incident Response Plan.” Source location 2025-0231-Response from Barts Health 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 Complete a specialist review of governance processes relating to this case, engage the Foster family, and share the outcome with HM Coroner.
Verbatim wording from the response “In order to gain additional assurance, the Trust has commissioned a review to be undertaken by a specialist within the North London Integrated Care Board and supported by NHSE to review” Source location 2025-0231-Response from Barts Health NHS Foundation Trust
Open published response
28 Oct 2024 Ian Gilmore HEGARTY · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1 Failure to follow falls-risk care plans View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ian Gilmore HEGARTY · 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
Ian Hegarty was admitted to hospital after a fall at home and later sustained an unwitnessed fall in hospital when the allocated staff member left the bay, causing a right femur fracture. His condition deteriorated and he died on 17 June 2024; the principal concern was that the care plan intended to reduce falls risk was not followed, with insufficient reassurance at the time of the inquest that the risk was being addressed.
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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow falls-risk care plans
Wider context from the report “1) That the plan of care put in place specifically to reduce the risk of falls for multiple patients was not followed .
I heard evidence that an internal investigation into the matter has been commenced but is not yet concluded. As such, there was insufficient reassurance, at the time of the inquest, that the risk is being addressed.
” 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 ward-based falls and enhanced-care risk-assessment training with senior-nurse oversight and refresher documentation sessions for staff.
Verbatim wording from the response “4. | Training, Falls and Enhanced Care risk assessments” Source location Response from Barts Health 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 Conduct weekly documentation audits, assurance meetings, metrics reviews and ward action planning across all six divisional wards.
Verbatim wording from the response “3. | Weekly documentation audits & action plans” Source location Response from Barts Health NHS Trust
Open published response
30 Aug 2024 Terence Harry Clark · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Patient safety investigations failing to review evidence relevant to governance and coronial investigations View source Failure to secure and document clinical apparatus relevant to investigations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Terence Harry 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
Terence Harry Clark, who had an impaired swallow and aspiration pneumonia, was admitted to hospital on 26 October 2023 and died there on 1 November 2023 after sustaining a cardiac arrest while waiting unescorted in an X-ray waiting area. Concerns included the discovery of liquid food in his airway, the unexplained removal and loss of his naso-gastric tube, and the failure to identify the tube’s removal as a significant factor during the patient safety investigation, which impeded investigation of the death.
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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Patient safety investigations failing to review evidence relevant to governance and coronial investigations
Wider context from the report “B. The Trust conducted a patient safety investigation into the circumstances leading to Mr Clark’s death, the investigation did not identify the removal of the NG tube as a significant factor worthy of scrutiny. Both of these issues raise a concern that the Trust can not adequately secure and review evidence relevant to governance and coronial investigations , necessary to mitigate risks of future fatalities.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to secure and document clinical apparatus relevant to investigations
Wider context from the report “A. Despite Mr Clark having been subject to a nil-by-mouth order for 24 hrs prior to collapse, cream-coloured liquid food was found in Mr Clark’s airway at autopsy. The NG tube, inserted on the day of death had been removed and misplaced prior to autopsy. No evidence exists to indicate, when the apparatus was removed, by whom, on whose instruction or why. The removal and loss of this apparatus impeded the proper investigation of this death.
” 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 Review and update the Bereavement policy to clarify when tubes, lines and devices remain in situ after sudden or unexpected death, including medical examiner involvement.
Verbatim wording from the response “Following this case, we are reviewing the Bereavement policy to clarify the guidance around removal of tubes, lines and devices. Where a sudden or unexpected death has occurred, the policy will mandate that tubes, lines and devices are left in situ until after:” Source location Response from Barts Health
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 Discuss the removal guidance at safety huddles with senior nursing and site teams to reinforce a lower threshold for coroners’ office discussion.
Verbatim wording from the response “This case has already been discussed at our safety huddles, with the senior nursing and site teams to underline the above and ensure a lower threshold for discussion with the coroners office should there be any doubt about removal of lines etc. Any conversation will be documented in the patient record.
We will be cascading the learning from this incident and embedding this within training across the Trust.” Source location Response from Barts Health
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 NG tube’s removal was not considered materially relevant to the care issues identified in the internal investigation.
Verbatim wording from the response “I will respond to these items together as they are interlinked. Mr Clark had an NG tube inserted on the 1st November 2023. It was not used prior to the X-Ray being conducted at which point Mr Clark had a cardiac arrest and died. The investigation into his death focused on the lack of nursing escort and therefore knowledge of Mr Clark’s DNACPR status when he arrested in the department which resulted in CPR being commenced. The NG tube was removed by ward staff on the day of Mr Clark’s death following a discussion with a doctor and the site manager. At this point a coroners referral had not been considered or made. The coroner’s referral was made on the 3rd November 2023.
The terms of reference for the concise internal investigation into Mr Clark’s death did not include review of the NGT removal as it was not considered to be materially relevant to any care issues identified.” Source location Response from Barts Health
Open published response
27 Aug 2024 Dave Yola Onawelo · Prevention of Future Deaths report East London
View report summary
Concerns raised 5 Failure to identify critically ill patients with high-risk pre-existing comorbidities View source Lack of compassion in emergency department care View source Patient congestion in emergency departments View source Lack of clinical curiosity in emergency department assessment View source Over-reliance on the NEWS algorithm in clinical assessment 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.
×
AI-generated summary
Dave Yola Onawelo · 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
Dave Yola Onawelo, who had sickle cell anaemia, became unwell on 30 December 2023 and was later transferred to hospital after developing difficulty breathing. While waiting in the emergency department, he deteriorated, suffered seizures and a cardiac arrest, and resuscitation was discontinued at 19.48. The principal concerns were that he was not adequately identified as critically ill and that earlier fluid resuscitation, blood transfusion and intravenous antibiotics may have resulted in a non-fatal outcome; patient congestion, over-reliance on the NEWS algorithm, and a lack of compassion and clinical curiosity were also identified as contributing factors.
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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify critically ill patients with high-risk pre-existing comorbidities
Wider context from the report “A. The Trust failed to adequately identify a critically ill patient with a pre-existing co-morbidity, sickle cell anaemia, that carried with it a high risk of acute deterioration . Earlier introduction of fluid resuscitation, blood transfusion and i/v antibiotics is likely to have resulted in a non-fatal outcome. Factors in the emergency department including, patient congestion, over-reliance on the NEWS algorithm and a lack of compassion and clinical curiosity contributed to the outcome.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of compassion in emergency department care
Wider context from the report “A. The Trust failed to adequately identify a critically ill patient with a pre-existing co-morbidity, sickle cell anaemia, that carried with it a high risk of acute deterioration. Earlier introduction of fluid resuscitation, blood transfusion and i/v antibiotics is likely to have resulted in a non-fatal outcome. Factors in the emergency department including, patient congestion, over-reliance on the NEWS algorithm and a lack of compassion and clinical curiosity contributed to the outcome.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Patient congestion in emergency departments
Wider context from the report “A. The Trust failed to adequately identify a critically ill patient with a pre-existing co-morbidity, sickle cell anaemia, that carried with it a high risk of acute deterioration. Earlier introduction of fluid resuscitation, blood transfusion and i/v antibiotics is likely to have resulted in a non-fatal outcome. Factors in the emergency department including, patient congestion , over-reliance on the NEWS algorithm and a lack of compassion and clinical curiosity contributed to the outcome.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clinical curiosity in emergency department assessment
Wider context from the report “A. The Trust failed to adequately identify a critically ill patient with a pre-existing co-morbidity, sickle cell anaemia, that carried with it a high risk of acute deterioration. Earlier introduction of fluid resuscitation, blood transfusion and i/v antibiotics is likely to have resulted in a non-fatal outcome. Factors in the emergency department including, patient congestion, over-reliance on the NEWS algorithm and a lack of compassion and clinical curiosity contributed to the outcome.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Over-reliance on the NEWS algorithm in clinical assessment
Wider context from the report “A. The Trust failed to adequately identify a critically ill patient with a pre-existing co-morbidity, sickle cell anaemia, that carried with it a high risk of acute deterioration. Earlier introduction of fluid resuscitation, blood transfusion and i/v antibiotics is likely to have resulted in a non-fatal outcome. Factors in the emergency department including, patient congestion, over-reliance on the NEWS algorithm and a lack of compassion and clinical curiosity contributed to the outcome.
” Open source report
25 Jul 2024 Elizabeth Grace Holder · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Failure to prevent predictable and avoidable falls View source Failure of governance systems to identify and reflect upon failings in care View source Failure to remediate factors contributing to death 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
Elizabeth Grace Holder · 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 Grace Holder, an 88-year-old woman recovering in hospital after surgery for a broken hip, fell while using a commode without supervision and died from a fatal intracerebral bleed. The concerns identified were that the Trust failed to prevent a predictable and avoidable fall and that its governance systems failed to identify care failings or act on factors contributing to her death.
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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent predictable and avoidable falls
Wider context from the report “1. The Trust’s failure to prevent a predictable and therefore avoidable fall which resulted in 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of governance systems to identify and reflect upon failings in care
Wider context from the report “2. Despite this incident activating the PSIRF process which resulted in the completion of an After Action Review (“AAR”), the Trust did not identify any sub-optimal aspects to Mrs Holder’s care. Accordingly, I have a concern regarding the failure of the Trust’s governance systems to;
a. Identify and reflect upon failings in care ,
b. Consequently, the failure of the trust to act in a way to remediate the factors that contributed to Mrs Holder’s 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to remediate factors contributing to death
Wider context from the report “2. Despite this incident activating the PSIRF process which resulted in the completion of an After Action Review (“AAR”), the Trust did not identify any sub-optimal aspects to Mrs Holder’s care. Accordingly, I have a concern regarding the failure of the Trust’s governance systems to;
a. Identify and reflect upon failings in care,
b. Consequently, the failure of the trust to act in a way to remediate the factors that contributed to Mrs Holder’s death .
” Open source report
13 May 2024 Elvon Paul Randolph Morton · Prevention of Future Deaths report East London
View report summary
Concerns raised 6 Failure to make and evidence a reasoned decision on rapid tranquilisation View source Failure to document key clinical decisions and treatment stages contemporaneously View source Failure of legal assurance functions to identify absent investigation and remediation evidence View source Failure to escalate and mitigate workload pressure affecting patient safety View source Failure to identify serious incidents and remediate sub-optimal practice View source Inadequacy and siloing of incident reporting and mortality review processes View source See 3 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. 10
Action
Provide staff training on mental-capacity assessment and deprivation-of-liberty safeguards.
Stated plannedThe respondent said that this action was planned when they made their response on 14 May 2024. View source
Action
Give specialties early sight of inquests to support timely incident reporting, review, learning responses and submission of key documentation.
Stated completedThe respondent said that this action was complete when they made their response on 14 May 2024. View source
Action
Recruit a learning-from-deaths lead to drive improvement and engage families, medical examiners and coroners.
Stated plannedThe respondent said that this action was planned when they made their response on 14 May 2024. View source
Action
Update ITU induction materials to require contemporaneous documentation or justified retrospective entries.
Stated completedThe respondent said that this action was complete when they made their response on 14 May 2024. View source
Action
Implement the Patient Safety Incident Response Framework, including reporting, multidisciplinary review and proportionate learning responses for unexpected deaths.
Stated in progressThe respondent said that this action was in progress when they made their response on 14 May 2024. View source
Action
Update rapid-tranquilisation guidance to require senior, clearly documented decision-making when its criteria cannot be followed.
Stated in progressThe respondent said that this action was in progress when they made their response on 14 May 2024. View source
Action
Review emergency-department working patterns and consultant cover through a wider discussion.
Stated plannedThe respondent said that this action was planned when they made their response on 14 May 2024. View source
Action
Deliver an A&E induction programme covering mental capacity, contemporaneous documentation, emergency medicines, sedation and escalation.
Stated plannedThe respondent said that this action was planned when they made their response on 14 May 2024. View source
Action
Arrange consultant attendance for specified emergency procedures in line with professional guidance.
Stated plannedThe respondent said that this action was planned when they made their response on 14 May 2024. View source
Action
Require on-call consultants to confirm remote access to the electronic healthcare record.
Stated plannedThe respondent said that this action was planned when they made their response on 14 May 2024. View source See 7 more actions
×
AI-generated summary
Elvon Paul Randolph Morton · 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
Elvon Paul Randolph Morton, a 38-year-old man with extensive co-morbidity, was admitted to hospital on 6 December 2022 with abdominal pain, vomiting, diarrhoea, dizziness and shortness of breath. He deteriorated and went into cardiac arrest while awaiting a CT scan under sedation; the inquest concluded that his death was caused by the combined effects of septic shock, oxycodone and lorazepam. Concerns included poor documentation of critical decisions, a flawed decision to sedate him, failures to manage workload pressures safely, and inadequate Trust processes for identifying and reviewing serious incidents.
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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make and evidence a reasoned decision on rapid tranquilisation
Wider context from the report “3. The decision to sedate Mr Morton was flawed. The lack of contemporary documentation impeded an effective coronary investigation and review of that clinical decision. In the absence of clear and reasoned evidence of decision making, weight must be attached to evidence heard that Elvon’s; size, sex and race triggered a heightened response by hospital staff to his agitation, leading to security officers being called. It was in this febrile atmosphere that the decision to utilise rapid tranquilisation, a simpler and faster process than anaesthesia and intubation, was made.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document key clinical decisions and treatment stages contemporaneously
Wider context from the report “1. Documentation of key stages in Mr Morton’s care was poor or non-existent. Critical decisions on; mental capacity, best interests, the choice of sedation, the amount of drug administered, the method of administration and the timing of administration were not clearly recorded. In multi-clinician treatment contemporary documentation is essential to preserve patient safety. In this case the lack of clear documentation meant that some clinicians were unaware that Elvon was sedated, whilst others were ignorant of the fact that he had declined 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of legal assurance functions to identify absent investigation and remediation evidence
Wider context from the report “4. A failure in governance at the Trust meant that this case was not identified as a serious incident. 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
Elvon’s relative youth, the unexpected nature of his death, the poor standard of documentation, the effect of patient acuity on the ability of staff to comply with regulatory duties and the Trust’s acceptance (in Feb 2023) that intubation should have been undertaken earlier, should have resulted in this matter being properly reviewed.
In this case the trust’s Datix incident reporting system, morbidity and mortality meeting process and SIRMAP procedure were inadequate. Each structure was siloed from the other, leading to inconsistent findings.
Additionally, despite preparing for an inquest, neither the Trust’s legal team nor external lawyers seemed capable of identifying to the trust the absence of meaningful evidence of investigation, reflection and remediation of practice that was undoubtedly required in this case.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate and mitigate workload pressure affecting patient safety
Wider context from the report “2. Witnesses blamed poor documentation on workload, specifically an influx of acute patients into the resuscitation bays. Despite this, no evidence was presented that any attempt was made to mitigate this pressure by, escalating the matter to the site manager , nor did the on-call ED consultant find it necessary to come in to the unit . These actions tend towards a “coping culture” inconsistent with patient safety .
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify serious incidents and remediate sub-optimal practice
Wider context from the report “4. A failure in governance at the Trust meant that this case was not identified as a serious incident. 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
Elvon’s relative youth, the unexpected nature of his death, the poor standard of documentation, the effect of patient acuity on the ability of staff to comply with regulatory duties and the Trust’s acceptance (in Feb 2023) that intubation should have been undertaken earlier, should have resulted in this matter being properly reviewed.
In this case the trust’s Datix incident reporting system, morbidity and mortality meeting process and SIRMAP procedure were inadequate. Each structure was siloed from the other, leading to inconsistent findings.
Additionally, despite preparing for an inquest, neither the Trust’s legal team nor external lawyers seemed capable of identifying to the trust the absence of meaningful evidence of investigation, reflection and remediation of practice that was undoubtedly required in this case.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequacy and siloing of incident reporting and mortality review processes
Wider context from the report “4. A failure in governance at the Trust meant that this case was not identified as a serious incident. 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
Elvon’s relative youth, the unexpected nature of his death, the poor standard of documentation, the effect of patient acuity on the ability of staff to comply with regulatory duties and the Trust’s acceptance (in Feb 2023) that intubation should have been undertaken earlier, should have resulted in this matter being properly reviewed.
In this case the trust’s Datix incident reporting system, morbidity and mortality meeting process and SIRMAP procedure were inadequate. Each structure was siloed from the other, leading to inconsistent findings.
Additionally, despite preparing for an inquest, neither the Trust’s legal team nor external lawyers seemed capable of identifying to the trust the absence of meaningful evidence of investigation, reflection and remediation of practice that was undoubtedly required in this case.
” 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 staff training on mental-capacity assessment and deprivation-of-liberty safeguards.
Verbatim wording from the response “The speciality medicine team have a teaching programme and induction of all levels of staff on Internal Professional standards and appropriate contemporaneous documentation. Training will also be provided to all staff grades to ensure that they understand how to assess mental capacity and the application of deprivation of liberty safeguards (DoLS).” Source location Response from Barts Health
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 Give specialties early sight of inquests to support timely incident reporting, review, learning responses and submission of key documentation.
Verbatim wording from the response “WXH have very carefully considered PFDs issued by the coroner in conjunction with late submissions and the impact this has on families, HM Coroner and ensuring preparedness for inquests. Steps have been taken to ensure that specialities have early sight of inquests. This will ensure that cases are reported via Datix, presented to PSIRM, learning responses and other key documentation are submitted in a timely manner (including statements). A proposal has been prepared to recruit a learning from deaths lead, their primary responsibility would be to drive improvement with stakeholder engagement including families, MEs, and coroners.” Source location Response from Barts Health
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 a learning-from-deaths lead to drive improvement and engage families, medical examiners and coroners.
Verbatim wording from the response “WXH have very carefully considered PFDs issued by the coroner in conjunction with late submissions and the impact this has on families, HM Coroner and ensuring preparedness for inquests. Steps have been taken to ensure that specialities have early sight of inquests. This will ensure that cases are reported via Datix, presented to PSIRM, learning responses and other key documentation are submitted in a timely manner (including statements). A proposal has been prepared to recruit a learning from deaths lead, their primary responsibility would be to drive improvement with stakeholder engagement including families, MEs, and coroners.” Source location Response from Barts Health
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 ITU induction materials to require contemporaneous documentation or justified retrospective entries.
Verbatim wording from the response “All doctors starting with ITU receive written pre-induction material to orientate them to the service. This is supplemented with face-to-face departmental induction. The induction material has been updated to state very clearly the need for contemporaneous documentation of clinical decision making wherever possible. Where not possible the documentation should reflect a retrospective entry with reasons why the entry had to be deferred.” Source location Response from Barts Health
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 the Patient Safety Incident Response Framework, including reporting, multidisciplinary review and proportionate learning responses for unexpected deaths.
Verbatim wording from the response “Since November 2023, WXH have been in the process of implementing the Patient Safety Incident Response Framework. There is a very clear directive that unexpected deaths need to be reported via Datix and presented at Patient Safety Incident Review Meeting (PSIRM) so that an MDT decision can be made in terms of the correct learning response. In cases where care is thought to have led to the patient’s death a PSII will be undertaken (these investigations can take up to 6 months to complete). In other cases, an After-Action Review or SWARM should be undertaken, (where staff ‘swarm’ to review an incident) will be undertaken, these need to be completed within 12 weeks. In other cases, the PSIRM chair will request that the case be presented to M&M and the outcome reported back to PSIRM.” Source location Response from Barts Health
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 rapid-tranquilisation guidance to require senior, clearly documented decision-making when its criteria cannot be followed.
Verbatim wording from the response “For assurance and complete clarity, the new rapid tranquilisation guidance which in the process of being recently updated is applicable to the whole of Barts Health has a very clear wording at the top “This guidance is not to be used in the hypoxic, hypovolemic or septic patient or in one in which intubation as opposed to rapid tranquilisation is required”. This will ensure decision making is senior and clearly documented if and when the guidance cannot be followed in cases where there is sound clinical justification to do so.” Source location Response from Barts Health
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 emergency-department working patterns and consultant cover through a wider discussion.
Verbatim wording from the response “The clinical review group agree that a wider discussion needs to take place to review WXH A&E working patterns and consultant cover, these discussions are complex and will likely take place over the next 12 months in conjunction with other improvement work being undertaken to manage patient flow within the hospital. Risks in relation to ED pressures including overcrowding and resus capacity are reflected on the WXH risk register.” Source location Response from Barts Health
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 an A&E induction programme covering mental capacity, contemporaneous documentation, emergency medicines, sedation and escalation.
Verbatim wording from the response “A specific induction programme has been formulated for the A&E which specifically covers themes such as the mental capacity act, contemporaneous documentation including emergency administered drugs with rationale, sedation and also escalation. The induction programme will be delivered and evidenced retained. A specific presentation relating to the Mental Capacity Act (MCA) its implementation in practice and the wider considerations will be delivered within the teaching programmes for all grades within A&E.” Source location Response from Barts Health
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 Arrange consultant attendance for specified emergency procedures in line with professional guidance.
Verbatim wording from the response “The Trust are supportive of staff that are increasingly managing high numbers of complex and acutely unwell patients. In this case, doctors sought and were provided with advice from a consultant on call. The consultant on call will attend to perform certain procedures (in line with the Royal College of Emergency Medicine guidance). With the benefit of hindsight, consultant presence would have provided support for the trainees.” Source location Response from Barts Health
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 Require on-call consultants to confirm remote access to the electronic healthcare record.
Verbatim wording from the response “Teams will ensure consultants on call confirm that they have remote access to the electronic healthcare record, this will eliminate the risk that documentation is not completed in relation to critical decisions.” Source location Response from Barts Health
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 case was not classified as a serious incident because reviews concluded that care failures did not cause or alter the outcome.
Verbatim wording from the response “This patient’s death on 7 December 2022 was unexpected and was reported as an incident via the Datix reporting system but it was not presented for multidisciplinary team (MDT) discussion as a serious incident. The fail safe whereby a mortality and morbidity meeting triggers Serious Incident Review Assurance Panel (SIRMAP) discussion did not happen because although learning was identified the outcome was not felt to have been due to failures in care. Following a prompt from HM Coroner via the legal team, the case was presented to SIRMAP in July 2023 and the panel identified learning but did not find that the outcome could have been altered in this case.” Source location Response from Barts Health
Open published response
19 Dec 2023 Margaret Ann Waylett · Prevention of Future Deaths report East London
View report summary
Concerns raised 5 Confusion between doctors about responsibility for patients with dual orthopaedic and medical needs View source Dangerously inadequate junior orthopaedic staffing levels View source Failure of orthogeriatricians to review patients without an orthopaedic referral View source Lack of readily accessible NEWS charts and scores during ward rounds View source Failure of on-call orthopaedic doctors to attend requested reviews 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
Margaret Ann Waylett · 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
Margaret Ann Waylett underwent surgery for a humerus fracture and developed ongoing low blood pressure and intermittent oxygen requirements. She later suffered a cardiac arrest and died in hospital after, according to the report, necessary medical intervention was not provided. Concerns included failures to provide medical reviews, lack of access to NEWS charts and confusion about responsibility for her care.
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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Confusion between doctors about responsibility for patients with dual orthopaedic and medical needs
Wider context from the report “(3) The inquest heard that there was confusion between the doctors as to who was responsible for the patient, in light of her dual orthopaedic and medical needs . Orthogeriatricians were aware of Mrs Waylett’s desaturation on 19 October 2022, but appeared to have considered it necessary for them to receive a referral from the orthopaedic team before they could carry out a review.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Dangerously inadequate junior orthopaedic staffing levels
Wider context from the report “(1) The inquest heard that nursing staff requested reviews by the on-call orthopaedic doctors on multiple occasions, without the doctors attending to carry out a review. A junior doctor described the junior orthopaedic staffing levels in the hospital as “dangerous” .
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of orthogeriatricians to review patients without an orthopaedic referral
Wider context from the report “(3) The inquest heard that there was confusion between the doctors as to who was responsible for the patient, in light of her dual orthopaedic and medical needs. Orthogeriatricians were aware of Mrs Waylett’s desaturation on 19 October 2022, but appeared to have considered it necessary for them to receive a referral from the orthopaedic team before they could carry out a review .
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of readily accessible NEWS charts and scores during ward rounds
Wider context from the report “(2) The inquest heard that the NEWS charts were not available on the ward rounds . The consultants did not therefore review the charts and were unaware of the frequently raised NEWS scores . The inquest heard that laptops on the ward were unwieldy and time consuming. There were no iPads or vital packs available for the ward team to easily access the NEWS scores .
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of on-call orthopaedic doctors to attend requested reviews
Wider context from the report “(1) The inquest heard that nursing staff requested reviews by the on-call orthopaedic doctors on multiple occasions, without the doctors attending to carry out a review . A junior doctor described the junior orthopaedic staffing levels in the hospital as “dangerous”.
” 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 Escalate orthopaedic patients with clinical concerns to the on-call medical, Critical Care Outreach or intensive care teams for support and further management.
Verbatim wording from the response “• The interaction and interface between the orthopaedic and orthogeriatric teams has been reviewed and updated, to ensure that there is no misunderstanding and that no patient who would benefit from a medical assessment is missed. Junior doctors in both teams have clear and defined roles and responsibilities designed to ensure patients get the attention that is needed. Any patient under the care of the Orthopaedic team for who there is a clinical concern is escalated to either the On call medical team or the Critical Care Outreach team and intensive care for support and further management.” Source location Response from Barts Health 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 Display on-call doctors’ contact information in relevant clinical areas.
Verbatim wording from the response “• A new process has been introduced, in which contact information for on call doctors is displayed in relevant clinical areas so that there is complete clarity about who should be contacted.” Source location Response from Barts Health 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 Increase laptop and iPad availability, verify Cerner compatibility and functionality, and provide computers on wheels for NEWS access.
Verbatim wording from the response “• The above has been supported by laptop and iPad device availability which has been increased, with devices having been tested and confirmed as compatible with Cerner and functional for use. Computers on wheels are also available for use.” Source location Response from Barts Health 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 Update the orthopaedic–orthogeriatric interface and define junior doctors’ roles and responsibilities for patient assessment.
Verbatim wording from the response “• The interaction and interface between the orthopaedic and orthogeriatric teams has been reviewed and updated, to ensure that there is no misunderstanding and that no patient who would benefit from a medical assessment is missed. Junior doctors in both teams have clear and defined roles and responsibilities designed to ensure patients get the attention that is needed. Any patient under the care of the Orthopaedic team for who there is a clinical concern is escalated to either the On call medical team or the Critical Care Outreach team and intensive care for support and further management.” Source location Response from Barts Health NHS 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 Existing access arrangements are considered sufficient to enable doctors to review NEWS data in each clinical area.
Verbatim wording from the response “• The senior medical leadership team in the hospital have made it clear to all doctors in the service that regular review of NEWS data is part of professional standards. A review has confirmed that there is enough access to ensure that this happens in each clinical area.” Source location Response from Barts Health NHS 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 Senior doctors consider staffing levels appropriate, disputing that junior orthopaedic staffing levels were dangerous.
Verbatim wording from the response “1. Concern: The inquest heard that nursing staff requested reviews by the on-call orthopaedic doctors on multiple occasions, without the doctors attending to carry out a review. A junior doctor described the junior orthopaedic staffing levels in the hospital as “dangerous”.” Source location Response from Barts Health NHS Trust
Open published response
16 Oct 2023 Claire Twinn · Prevention of Future Deaths report East London
View report summary
Concerns raised 5 Failure to make reasonable adjustments for communication and impaired respiratory function when making clinical decisions View source Failure to record clear safety-netting advice to carers View source Delays in reporting radiological chest x-rays View source Lack of specialised learning disability nursing input to facilitate clear communication View source Failure to record discharge and non-admission decisions concerning oxygen monitoring and remedial oxygen therapy 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
Claire Twinn · 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
Claire Twinn, a 47-year-old woman with Down’s syndrome, severe learning disability, and complex heart and lung conditions, became unwell and attended hospital with low oxygen saturations and symptoms including cough, sickness, and diarrhoea. She was diagnosed with suspected bilateral pneumonia, discharged on oral antibiotics, and found deceased by her family the following morning. The principal concerns were that she was discharged rather than admitted for monitoring and oxygen therapy, reasonable adjustments and specialised learning disability nursing input were not provided, safety-netting advice was not recorded, and the chest X-ray report was delayed.
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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make reasonable adjustments for communication and impaired respiratory function when making clinical decisions
Wider context from the report “1. Ms Twinn’s disability played a role in the provision of sub-optimal care, reasonable adjustment was not made for; her inability to communicate clearly and her impaired respiratory function when arriving at clinical decisions .
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record clear safety-netting advice to carers
Wider context from the report “2. Neither the trust decision to discharge Ms Twinn and not admit for continued monitoring of oxygen levels and remedial oxygen therapy, nor clear safety-netting advice to carers was recorded in the clinical record .
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in reporting radiological chest x-rays
Wider context from the report “4. A radiological report of the chest x-ray taken on 15th December 2023 was not reported until 25th December 2023 .
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of specialised learning disability nursing input to facilitate clear communication
Wider context from the report “3. Ms Twinn’s treatment did not involve any specialised learning disability nursing input to facilitate clear communication with Ms Twinn.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record discharge and non-admission decisions concerning oxygen monitoring and remedial oxygen therapy
Wider context from the report “2. Neither the trust decision to discharge Ms Twinn and not admit for continued monitoring of oxygen levels and remedial oxygen therapy , nor clear safety-netting advice to carers was recorded in the clinical record .
” 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 Increase Emergency Department imaging-reporting radiologists and radiographers to near-full capacity.
Verbatim wording from the response “Since the time of the incident, we have increased our reporting radiologists and radiographers to near full capacity and are in the process of recruiting further reporters in order to reduce the turnaround time. At present, we insource our plain films to all reporters and outsource ones that may be reaching the expected time frame.” Source location Response from Barts Health 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 Deliver vulnerable-patient communication teaching during induction and monthly consultant meetings.
Verbatim wording from the response “A training package has been put together around communicating with vulnerable patients, which includes a case study of a patient with LD in the Emergency Department. It involves looking at factors relating to the clinician, the environment and the patient that might make the situation more complex. Teaching is also taking place on induction and at monthly Consultant meetings. Finally, we are procuring specialist equipment in the form of a multi-sensory mobile unit to be used when needed alongside smaller items, including communication tools, for use with most complex patients.” Source location Response from Barts Health 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 Procure a mobile multisensory unit and smaller communication tools for complex patients.
Verbatim wording from the response “A training package has been put together around communicating with vulnerable patients, which includes a case study of a patient with LD in the Emergency Department. It involves looking at factors relating to the clinician, the environment and the patient that might make the situation more complex. Teaching is also taking place on induction and at monthly Consultant meetings. Finally, we are procuring specialist equipment in the form of a multi-sensory mobile unit to be used when needed alongside smaller items, including communication tools, for use with most complex patients.” Source location Response from Barts Health 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 Increase proactive attendance by specialist learning-disability nurses in the Emergency Department.
Verbatim wording from the response “For assurance, the LD team will audit the discharge advice given to this patient cohort over a period of one month in the first instance. We are also ensuring greater pro-active attendance” Source location Response from Barts Health 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 Develop a training package on communicating with vulnerable patients, including a learning-disability Emergency Department case study.
Verbatim wording from the response “A training package has been put together around communicating with vulnerable patients, which includes a case study of a patient with LD in the Emergency Department. It involves looking at factors relating to the clinician, the environment and the patient that might make the situation more complex. Teaching is also taking place on induction and at monthly Consultant meetings. Finally, we are procuring specialist equipment in the form of a multi-sensory mobile unit to be used when needed alongside smaller items, including communication tools, for use with most complex patients.” Source location Response from Barts Health 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 Recruit further imaging reporters to reduce reporting turnaround times.
Verbatim wording from the response “Since the time of the incident, we have increased our reporting radiologists and radiographers to near full capacity and are in the process of recruiting further reporters in order to reduce the turnaround time. At present, we insource our plain films to all reporters and outsource ones that may be reaching the expected time frame.” Source location Response from Barts Health NHS 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 chest radiograph was reported within the department’s ten-working-day timeframe, despite being completed outside normal working hours.
Verbatim wording from the response “4. A radiological report of the chest x-ray taken on 15th December 2022 was not reported until 25th December 2022.” Source location Response from Barts Health NHS Trust
Open published response
5 Oct 2023 Iris Elaine Fordham · Prevention of Future Deaths report East London
View report summary
Concerns raised 6 Culture of indifference to safe and effective practice View source Failure of clinical staff to read essential parts of the clinical record when providing care View source Failure to address individual care failings through disciplinary or regulatory channels View source Failure to complete falls care plans View source Poor quality of clinical record keeping View source Failure to complete falls risk assessments View source See 3 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.
×
AI-generated summary
Iris Elaine Fordham · 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
Iris Elaine Fordham was admitted to hospital after an unwitnessed fall and concerns about her ability to keep herself safe due to Alzheimer’s disease. Failures to complete a falls risk assessment, falls care plan and enhanced care assessment led to the removal of 1:1 care, after which she sustained a fractured neck of femur in a further unwitnessed fall. She underwent surgical repair and died in a step-down care centre; concerns included poor clinical record-keeping, failures in falls-risk management and the absence of action through disciplinary or regulatory channels.
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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Culture of indifference to safe and effective practice
Wider context from the report “4. The fact that the failures at (2) & (3) were not detected and remediated by successive clinical staff members suggests that they did not read essential parts of the clinical record when providing care. The cumulative failings, on the part of multiple healthcare professionals suggests a culture of indifference inimical to the provision of safe and effective practice.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of clinical staff to read essential parts of the clinical record when providing care
Wider context from the report “4. The fact that the failures at (2) & (3) were not detected and remediated by successive clinical staff members suggests that they did not read essential parts of the clinical record when providing care . The cumulative failings, on the part of multiple healthcare professionals suggests a culture of indifference inimical to the provision of safe and effective practice.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to address individual care failings through disciplinary or regulatory channels
Wider context from the report “5. The Trust has not considered any step to resolve individual failings in care through disciplinary or regulatory channels .
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete falls care plans
Wider context from the report “3. The consequence of (2) was that no falls care plan was completed .
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Poor quality of clinical record keeping
Wider context from the report “1. The poor quality of recording clinical records impeded the Trust's governance processes, in that the author of a serious incident investigation was unable to rely on clear evidence to understand why essential actions were not carried out in Ms Fordham's care.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete falls risk assessments
Wider context from the report “2. The Trust failed to complete a falls risk assessment of Ms Fordham.
” Open source report
8 Sep 2023 Lynsey Sarah Smalley · Prevention of Future Deaths report North West Wales
View report summary
Concerns raised 5 Investigation reports containing conflicting evidence View source Lack of strategic planning and collaboration in governance processes View source Risk of full or partial loss of paper medical notes during transfer View source Failure of paper-based medical records to provide all relevant care information to involved individuals and organisations View source Delays in identifying and completing proposed actions 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.
×
AI-generated summary
Lynsey Sarah Smalley · 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
Lynsey Sarah Smalley, aged 42, set fire to her bed at home during an acute psychotic episode on 8 April 2021. She suffered inhalation injuries, was admitted to intensive care, and died at Ysbyty Gwynedd, Bangor on 16 May 2021. The substantive concerns were conflicting investigation reports, disjointed patient-safety and governance processes, delays in completing actions, and risks arising from paper-based medical records that may impede continuity of care.
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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Investigation reports containing conflicting evidence
Wider context from the report “a. The Health Board provided 3 investigation reports into the death, two of which contained conflicting evidence . One responded to Lynsey’s brother’s complaint. It is clear that there was no strategic plan or collaboration in governance processes. Furthermore, there were a number of proposed actions which took nearly two years to identify and complete. The time it took to identify and complete actions, together with governance processes are matters which I have raised previously with the Health Board in previous Prevention of future Death Reports. If there are such disjointed patient safety and governance processes learning will not be effective and deaths will continue to occur or will occur into the future.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of strategic planning and collaboration in governance processes
Wider context from the report “a. The Health Board provided 3 investigation reports into the death, two of which contained conflicting evidence. One responded to Lynsey’s brother’s complaint. It is clear that there was no strategic plan or collaboration in governance processes . Furthermore, there were a number of proposed actions which took nearly two years to identify and complete. The time it took to identify and complete actions, together with governance processes are matters which I have raised previously with the Health Board in previous Prevention of future Death Reports. If there are such disjointed patient safety and governance processes learning will not be effective and deaths will continue to occur or will occur into the future.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Risk of full or partial loss of paper medical notes during transfer
Wider context from the report “b. A number of individuals and organisations are involved in the care of those under mental health teams or at times have contact with patients e.g. CMHT, Home Treatment Teams, Psychiatrists, Occupational therapists, Care Coordinators, out of hours crisis service (local authority based in Gwynedd), Police, Ambulance Service etc. As medical records remain paper based not all individuals or organisations who need to understand a patient’s circumstances/care/treatment are privy to all aspects of care/treatment. In addition, where a CMHT patient is receiving in-patient mental heath treatment the paper notes are transferred to the hospital setting. There is a risk that notes will become lost in full / in part. Having medical records electronically will not only allow full access to all notes to those who require which will inform future care/treatment but will also ensure effective continuity of care, without the risk of missing or lost notes. I have previously issued a Prevention of Future Deaths Report on this point, a copy of which was also sent to ████████, Health Minister.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of paper-based medical records to provide all relevant care information to involved individuals and organisations
Wider context from the report “b. A number of individuals and organisations are involved in the care of those under mental health teams or at times have contact with patients e.g. CMHT, Home Treatment Teams, Psychiatrists, Occupational therapists, Care Coordinators, out of hours crisis service (local authority based in Gwynedd), Police, Ambulance Service etc. As medical records remain paper based not all individuals or organisations who need to understand a patient’s circumstances/care/treatment are privy to all aspects of care/treatment. In addition, where a CMHT patient is receiving in-patient mental heath treatment the paper notes are transferred to the hospital setting. There is a risk that notes will become lost in full / in part. Having medical records electronically will not only allow full access to all notes to those who require which will inform future care/treatment but will also ensure effective continuity of care, without the risk of missing or lost notes. I have previously issued a Prevention of Future Deaths Report on this point, a copy of which was also sent to ████████, Health Minister.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in identifying and completing proposed actions
Wider context from the report “a. The Health Board provided 3 investigation reports into the death, two of which contained conflicting evidence. One responded to Lynsey’s brother’s complaint. It is clear that there was no strategic plan or collaboration in governance processes. Furthermore, there were a number of proposed actions which took nearly two years to identify and complete . The time it took to identify and complete actions, together with governance processes are matters which I have raised previously with the Health Board in previous Prevention of future Death Reports. If there are such disjointed patient safety and governance processes learning will not be effective and deaths will continue to occur or will occur into the future.
” Open source report
7 Sep 2023 Sultana Choudhury · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Failure to withhold low molecular weight heparin VTE prophylaxis in the presence of active bleeding View source Failure to diagnose ongoing renal haemorrhage View source Failure to adequately monitor patients during 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
Sultana Choudhury · 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
Sultana Choudhury died in hospital on 17 December 2022 after suffering a renal haemorrhage following a renal biopsy, leading to hypovolaemia and cardiac arrest. The concerns included failure to diagnose the ongoing haemorrhage, administration of VTE prophylaxis despite haematuria, and inadequate monitoring during her admission.
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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to withhold low molecular weight heparin VTE prophylaxis in the presence of active bleeding
Wider context from the report “2. The clinical decision to administer VTE prophylaxis in the form of low molecular weight heparin on admission to a patient with a patent bleed, evidenced by haematuria .
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to diagnose ongoing renal haemorrhage
Wider context from the report “1. The trust’s failure to diagnose an obvious ongoing renal haemorrhage in a patient with; a recent history of renal biopsy, worsening clinical observations in keeping with hypovolaemia and a plummeting haemoglobin count.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately monitor patients during admission
Wider context from the report “3. The failure to adequately monitor Mrs Choudhury during her 3-day admission that allowed her to deteriorate into a preventable peri-arrest state.
” Open source report
24 Jul 2023 Christine Goodfriday Nakaefeero · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Failure of VTE risk assessment criteria to include relevant risk factors View source Failure to maintain patients within the gynaeology care pathway and ensure timely surgery View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Christine Goodfriday Nakaefeero · 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
Christine Goodfriday Nakaefeero was found unresponsive at home on 21 June 2022 and died from a pulmonary embolism caused by a deep vein thrombosis. The report raises concerns that recommended hysterectomy surgery for her uterine fibroids was not arranged, and that the VTE assessment did not account for her large fibroids and use of tranexamic acid.
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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of VTE risk assessment criteria to include relevant risk factors
Wider context from the report “2. The clinicians treating Ms Nakaefeero assessed her VTE risk utilising an established algorithm based on national guidance. The assessment was undertaken appropriately but it failed to identify two risk factors which made the formation of a DVT more likely, namely, large uterine fibroids and the use of tranexamic acid. I have concerns that the omission of these factors in the assessment criteria limited the effectiveness of the risk assessment.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain patients within the gynaeology care pathway and ensure timely surgery
Wider context from the report “1. Ms Nakaefeero was assessed at a Gynae-oncology clinic in early 2019. The patient was diagnosed as not suffering from any form of cancer and was therefore referred on to the “benign” gynaeology team.
Ms Nakaefeero was advised that it was likely that the most effective treatment for her condition was a hysterectomy. It was expected that the likely wait for this treatment would be 6 months.
Ms Nakaefeero was not allocated an appointment and therefore had not received the necessary surgery by the time of her death in June 2022. Had the surgery been undertaken it is probable that she would not have developed a pulmonary embolism.
Although the trust has investigated these circumstances and implemented change, no clear explanation could be offered for why the deceased slipped out of this care pathway. I am not satisfied that the risk of re-occurrence has been properly addressed.
” 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 Implement a fully electronic outpatient outcome system to record clinic outcomes in real time and maintain an auditable patient pathway trail.
Verbatim wording from the response “We are implementing a fully electronic outpatient outcome system using outpatient organiser on our Cerner millennium system. This provides real time outcoming within clinics, and an electronic audit trail to track the patient along the pathway.
Alongside the use of electronic outcome forms, the Trust is rolling out LUNA, a digital monitoring tool for patient tracking lists which will replace our current electronic waiting list tool at the end of September 2023. LUNA has the ability to pick up errors allowing staff to make corrections. It has an AI tool that reviews letters for key text which can indicate where incorrect discharge is matched with a letter stating the patient should be seen again. Therefore, this can be corrected, and a follow up appointment sent to the patient .” Source location Response from Barts Health 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 Roll out LUNA as the patient tracking-list tool, replacing the existing electronic waiting-list system and identifying errors requiring correction or follow-up.
Verbatim wording from the response “We are implementing a fully electronic outpatient outcome system using outpatient organiser on our Cerner millennium system. This provides real time outcoming within clinics, and an electronic audit trail to track the patient along the pathway.
Alongside the use of electronic outcome forms, the Trust is rolling out LUNA, a digital monitoring tool for patient tracking lists which will replace our current electronic waiting list tool at the end of September 2023. LUNA has the ability to pick up errors allowing staff to make corrections. It has an AI tool that reviews letters for key text which can indicate where incorrect discharge is matched with a letter stating the patient should be seen again. Therefore, this can be corrected, and a follow up appointment sent to the patient .” Source location Response from Barts Health NHS 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 Insufficient evidence exists to justify changing the national VTE risk assessment tool for tranexamic acid use or pelvic fibroids.
Verbatim wording from the response “The Trust has discussed this matter at the Venous Thromboembolism Prevention Committee and reviewed the available published evidence regarding the relative risk of these two factors and any other available guidance. Current evidence of relative risk is very limited and subject to debate nationally and there are no specific College or National guidelines available dealing with these specific topics.” Source location Response from Barts Health NHS Trust
Open published response
11 Jul 2023 Mr John Michael James · Prevention of Future Deaths report East London
View report summary
Concerns raised 1 Lack of electronic alerts escalating non-administration of prescribed anticoagulation medication to the medical team View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr John Michael James · 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 John Michael James was admitted to hospital with malnutrition and a bowel obstruction caused by an adenocarcinoma, and later underwent surgery and intensive care. He died from a pulmonary embolism after three missed doses of prescribed anticoagulation medication; the report raised concern that the refusals were not escalated and that there was no electronic alert to notify medical staff when doses were not administered.
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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of electronic alerts escalating non-administration of prescribed anticoagulation medication to the medical team
Wider context from the report “The refusal of anti-coagulation medication was not brought to the attention of medical staff. The administration of anti-coagulation medication to patients like Mr James, is vital for reducing the risk of a venous thrombo-embolism, a potentially life-threatening condition. There is no electronic prompt/alert to highlight to the medical team when prescribed anticoagulation medication is not administered.
The Trust’s internal investigator recognised that a fail-safe should be put in place within the electronic records, to ensure escalation to the medical team where doses of prescribed anti-coagulation are not administered. Such a measure could prevent similar deaths from occurring. It was considered that this measure could assist in preventing future deaths not just locally, but at a wider level.
” 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 Update Millennium training so multidisciplinary teams understand and use visual flags to prevent omission of critical medications.
Verbatim wording from the response “Our response:
The electronic prescribing and medicines administration system (ePMA) currently has functionality (all of which is accessible via Millennium®) to reduce harm associated with missed or late medication administration. This includes visual aids in the form of a red tile if a dose is delayed by more than 2 hours. This visual flag is available to all users. Millennium training will be updated to reflect learning from this case to ensure that multi-professional teams know how to use the flag system to ensure critical medications are not omitted.” Source location Response from Bart Health NHS Trust
Open published response
13 Jun 2023 Raquel Mellonie Harper · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Failure to escalate monitoring in accordance with the NEWS policy View source Failure to apply the PE policy in accordance with its specific wording View source Lack of thorough history taking and verification of baseline oxygen saturation 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
Raquel Mellonie Harper · 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
Raquel Mellonie Harper attended Whipps Cross Hospital with shortness of breath and difficulty breathing, but a D Dimer test was not carried out and her condition later deteriorated. She suffered a cardiac arrest and died at the hospital on 25 June 2021. Concerns included inadequate history taking, failure to escalate monitoring after a high NEWS score, and disagreement or unclear wording in the Trust’s pulmonary embolism policy.
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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate monitoring in accordance with the NEWS policy
Wider context from the report “2. There was a lack of escalation of monitoring following the NEWS score of 10 . It is of concern that the NEWS policy was not complied with by the nursing 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to apply the PE policy in accordance with its specific wording
Wider context from the report “3. There was disagreement between senior clinicians as to how the Trust’s PE policy should have been applied. The policy is often not used in accordance with the specific wording . For example, the requirement for pleuritic chest pain is often ignored in practice . A senior clinician within the Trust considered that the caveat for pleuritic chest pain in the policy should be reviewed. In addition, the senior clinician described some of the wording in the policy as “clumsy”. In light of this, the Trust may wish to review the policy.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of thorough history taking and verification of baseline oxygen saturation
Wider context from the report “1. There was a lack of thorough history taking and a number of assumptions were made on the basis of Raquel’s high BMI . There was an assumed chronic low oxygen saturation with no evidence that the doctors had checked the records available or asked the patient about her baseline . The oxygen saturations recorded in the Barts sleep apnoea clinic in 2015 and 2016 were noted to be 99% and 100%.
” Open source report
1 Jul 2022 Daniel Xavier · Prevention of Future Deaths report East London
View report summary
Concerns raised 4 Failure to account for learning disability when taking a clear clinical history View source Failure to provide effective referral communication and formal handover to the surgical team View source Failure to consider and act on dangerously elevated creatinine results before discharge View source Failure to review clinical records before accepting a surgical referral View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Daniel Xavier · 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
Daniel Xavier attended the emergency department on 21 October 2021 with a history of painful haemorrhoids and an accompanying history of constipation. A venous blood gas showed an abnormally high creatinine level, but the result was not considered before he was discharged; he later became increasingly unwell, suffered a cardiac arrest, and could not be resuscitated. The report identified concerns about the failure to act on the blood result, a chaotic referral and inadequate handover, and insufficient consideration of his learning disability when taking his history.
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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to account for learning disability when taking a clear clinical history
Wider context from the report “3. Due regard was not given to Mr Xavier’s learning disability during his admission on 21st October 2021. Insufficient time and care was taken to establish a clear history from the patient , most pertinently his 7-day history of constipation.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide effective referral communication and formal handover to the surgical team
Wider context from the report “2. Mr Xavier’s referral to the surgical team by his GP was chaotic. No telephone contact was made between the GP and the on call surgical team. Mr Xavier was therefore triaged by a ED nurse and subsequently, a rapid assessment team junior doctor before he was brought to the attention of the surgical team. Despite these assessments, no formal handover was provided to the surgical team, setting out the extent of the history, clinical observations and diagnostic processes that had previously taken place . Despite these shortcomings, the surgical team accepted the referral without considering Mr Xavier’s clinical records beforehand.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider and act on dangerously elevated creatinine results before discharge
Wider context from the report “1. Prior to Mr Xavier’s discharge from hospital on the evening of 21st October 2021, the deceased’s venous blood gas results were not considered and acted upon by staff . The results, available from 13.17, indicated that Mr Xavier had a dangerously elevated creatinine level . Evidence heard at inquest indicated that had the results been considered, Mr Xavier would not have been discharged, he would have been escalated to the resuscitation department. Further, the Trust accepted that had the creatinine levels been acted upon, it is likely that the outcome for Mr Xavier could have been different.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review clinical records before accepting a surgical referral
Wider context from the report “2. Mr Xavier’s referral to the surgical team by his GP was chaotic. No telephone contact was made between the GP and the on call surgical team. Mr Xavier was therefore triaged by a ED nurse and subsequently, a rapid assessment team junior doctor before he was brought to the attention of the surgical team. Despite these assessments, no formal handover was provided to the surgical team, setting out the extent of the history, clinical observations and diagnostic processes that had previously taken place. Despite these shortcomings, the surgical team accepted the referral without considering Mr Xavier’s clinical records beforehand .
” 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 Add a learning-disability section to statutory and mandatory training.
Verbatim wording from the response “Across the hospital, all specialties will be asked to have learning disability (LD) training during their governance days this year. The hospital currently has a LD nurse on site 2 days a week and with future appointments will have one 4-5 days a week. There will be a LD section as part of statutory and mandatory training by the end of the year.” Source location Response from Barts Health NHS
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 Examine whether electronic patient records can track VBGs and provide an audit trail and completion alert.
Verbatim wording from the response “In the medium term, the department is examining whether VBGs can be tracked on the electronic patient records system in the same way as happens with ECGs. This would have the additional benefit of providing a more robust audit trail than paper and giving an immediate alert that a test had been completed.” Source location Response from Barts Health NHS
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 Apply a vulnerable-patient flag to all emergency-department patients with a learning disability.
Verbatim wording from the response “Within ED, all patients with a learning disability will have the vulnerable patient flag applied to them on the electronic patient records system to raise awareness. As part of an SOP, all patients with a learning disability will be discussed with by a senior clinician (ST3 plus) as a minimum and prioritised for early review. The SOP is part of the induction package.” Source location Response from Barts Health NHS
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 Require senior-clinician discussion and early review for all emergency-department patients with a learning disability through the SOP and induction package.
Verbatim wording from the response “Within ED, all patients with a learning disability will have the vulnerable patient flag applied to them on the electronic patient records system to raise awareness. As part of an SOP, all patients with a learning disability will be discussed with by a senior clinician (ST3 plus) as a minimum and prioritised for early review. The SOP is part of the induction package.” Source location Response from Barts Health NHS
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 internal professional standards for specialty teams reviewing emergency-department patients, including training on locating relevant electronic records information.
Verbatim wording from the response “The site is developing internal professional standards for speciality teams reviewing patients in the emergency department. This will include training on where to find all relevant information including tests carried out and GP consultation within the electronic patient records system. The expectation is to have these agreed by the end of October 2022.” Source location Response from Barts Health NHS
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 learning-disability training for hospital specialties during governance days.
Verbatim wording from the response “Across the hospital, all specialties will be asked to have learning disability (LD) training during their governance days this year. The hospital currently has a LD nurse on site 2 days a week and with future appointments will have one 4-5 days a week. There will be a LD section as part of statutory and mandatory training by the end of the year.” Source location Response from Barts Health NHS
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 Brief staff to perform three safety checks of results at availability, referral or movement to SDEC, and discharge.
Verbatim wording from the response “Learning from the incident has been shared widely within the department, including at induction and at daily safety briefings. Furthermore, all staff have been briefed on the need for 3 pauses for safety, whereby checks are undertaken when the result is first available, then rechecked at the point of referral/movement to SDEC (Same Day Emergency Care) unit and then a further check at the point of discharge.” Source location Response from Barts Health NHS
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 Evaluate the VBG process and additional resources using quality improvement methodology.
Verbatim wording from the response “In response to this incident, the Emergency Department (ED) are piloting a new process for the management of VBG results. The process requires the person taking blood to take the result for sign off straight away and there is an allocated clinician who is dedicated solely to review VBGs, sign ECGs and take any resulting actions immediately. The effectiveness of this process and the additional resources required will be evaluated by October 2022 and developed using quality improvement methodology.” Source location Response from Barts Health NHS
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 Work with primary-care colleagues to improve the referral system.
Verbatim wording from the response “The Trust is working with senior colleagues from primary care to improve the system. Consideration is being given to introducing a single referral telephone line where calls are screened and accepted. We expect to have agreed a system by the end of October 2022. The principle will be that there is automatic acceptance of referrals from GPs.” Source location Response from Barts Health NHS
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 Pilot a dedicated process for immediate VBG result sign-off, clinician review, ECG signing and resulting actions.
Verbatim wording from the response “In response to this incident, the Emergency Department (ED) are piloting a new process for the management of VBG results. The process requires the person taking blood to take the result for sign off straight away and there is an allocated clinician who is dedicated solely to review VBGs, sign ECGs and take any resulting actions immediately. The effectiveness of this process and the additional resources required will be evaluated by October 2022 and developed using quality improvement methodology.” Source location Response from Barts Health NHS
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 Consider introducing a screened single referral telephone line with automatic acceptance of GP referrals.
Verbatim wording from the response “The Trust is working with senior colleagues from primary care to improve the system. Consideration is being given to introducing a single referral telephone line where calls are screened and accepted. We expect to have agreed a system by the end of October 2022. The principle will be that there is automatic acceptance of referrals from GPs.” Source location Response from Barts Health NHS
Open published response
22 Feb 2022 VAN THAI TUYEN · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Lack of a unified approach to address ongoing use of misplaced nasogastric tubes View source Continuing use of misplaced nasogastric tubes to administer liquids or medications 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
VAN THAI TUYEN · 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
Van Thai Tuyen was admitted to hospital for stroke treatment and, after a nasogastric tube was misplaced into his right lung, approximately 300ml of liquid feed was administered through it. He died from cavitating necrotising pneumonia. The principal concerns were the use of misplaced nasogastric tubes, the recurrence of such incidents, and the absence of a unified approach to preventing avoidable deaths from this problem.
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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a unified approach to address ongoing use of misplaced nasogastric tubes
Wider context from the report “(1) Using a misplaced nasogastric tube is recognised as a ‘never event’, namely an event which is wholly preventable and should never happen.
(2) The court heard evidence at the inquest that an NHS improvement patient safety alert issued in 2016 identified that between 2011-2016 there had been 95 incidents of misplaced nasogastric tubes used to administer fluids or medication, 32 of which resulted in death.
(3) The court heard that there had been Barts NHS Trust had had at least 7 incidents relating to misplaced nasogastric tube since 2012.
(4) The court heard that the use of misplaced nasogastric tubes to administer liquids or medications continues to take place in Trusts across the country
(5) The court heard that there is no unified approach to address the on going issue of avoidable deaths caused by using misplaced nasogastric tubes .
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Continuing use of misplaced nasogastric tubes to administer liquids or medications
Wider context from the report “(1) Using a misplaced nasogastric tube is recognised as a ‘never event’, namely an event which is wholly preventable and should never happen.
(2) The court heard evidence at the inquest that an NHS improvement patient safety alert issued in 2016 identified that between 2011-2016 there had been 95 incidents of misplaced nasogastric tubes used to administer fluids or medication, 32 of which resulted in death.
(3) The court heard that there had been Barts NHS Trust had had at least 7 incidents relating to misplaced nasogastric tube since 2012.
(4) The court heard that the use of misplaced nasogastric tubes to administer liquids or medications continues to take place in Trusts across the country
(5) The court heard that there is no unified approach to address the on going issue of avoidable deaths caused by using misplaced nasogastric tubes.
” Open source report
7 Jan 2022 Mrs Surekha Pandharinath Shivalkar · Prevention of Future Deaths report East London
View report summary
Concerns raised 6 Failure to use targeted factual communication between surgical and anaesthetic teams during surgery View source Failure to communicate a surgeon's reasons for leaving surgery to the surgical team View source Failure to effectively monitor when a surgeon leaves theatre View source Lack of a system to assess the appropriateness of a surgeon leaving surgery View source Lack of a formal preoperative risk assessment tool requirement View source Failure to record a surgeon's early departure in the surgical notes View source See 3 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.
×
AI-generated summary
Mrs Surekha Pandharinath Shivalkar · 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 Surekha Pandharinath Shivalkar, aged 78, underwent revision total hip replacement surgery and subsequently developed profound hypotension, multiorgan failure and cardiac arrest, dying despite intensive treatment. Concerns included the absence of a formal preoperative risk assessment tool, poor communication between the surgical and anaesthetic teams, and inadequate systems concerning the senior surgeon’s departure before the operation concluded.
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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use targeted factual communication between surgical and anaesthetic teams during surgery
Wider context from the report “2. Poor communication between the orthopaedic surgical team and the anaesthetist during surgery led to a collective failure to identify a critically ill patient. General and non-specific questions regarding the patient’s welfare passed between the two teams but no targeted questions requiring clear factual responses were asked . Had such questions been put, a different outcome may have arisen.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate a surgeon's reasons for leaving surgery to the surgical team
Wider context from the report “3. The Senior Consultant surgeon left the surgery prior to its conclusion, lengthening the procedure. The Consultant did not effectively communicate his reasons for leaving the surgery to the other members of the surgical team , neither did the surgical notes refer to his early departure. The Consultants statement to the court did not indicate that he had left the surgery before its conclusion. No system was in place to; assess whether a decision to leave surgery was appropriate, or to effectively monitor when a surgeon leaves theatre.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to effectively monitor when a surgeon leaves theatre
Wider context from the report “3. The Senior Consultant surgeon left the surgery prior to its conclusion, lengthening the procedure. The Consultant did not effectively communicate his reasons for leaving the surgery to the other members of the surgical team, neither did the surgical notes refer to his early departure. The Consultants statement to the court did not indicate that he had left the surgery before its conclusion. No system was in place to; assess whether a decision to leave surgery was appropriate, or to effectively monitor when a surgeon leaves theatre .
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system to assess the appropriateness of a surgeon leaving surgery
Wider context from the report “3. The Senior Consultant surgeon left the surgery prior to its conclusion, lengthening the procedure. The Consultant did not effectively communicate his reasons for leaving the surgery to the other members of the surgical team, neither did the surgical notes refer to his early departure. The Consultants statement to the court did not indicate that he had left the surgery before its conclusion. No system was in place to; assess whether a decision to leave surgery was appropriate , or to effectively monitor when a surgeon leaves theatre.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal preoperative risk assessment tool requirement
Wider context from the report “1. No formal risk assessment tool was adopted to assess preoperative risk prior to Mrs Shivalkar's total hip replacement revision surgery. Despite policy changes at Barts Health NHS Trust since 2018, there remains no requirement to utilise such a tool .
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record a surgeon's early departure in the surgical notes
Wider context from the report “3. The Senior Consultant surgeon left the surgery prior to its conclusion, lengthening the procedure. The Consultant did not effectively communicate his reasons for leaving the surgery to the other members of the surgical team, neither did the surgical notes refer to his early departure . The Consultants statement to the court did not indicate that he had left the surgery before its conclusion. No system was in place to; assess whether a decision to leave surgery was appropriate, or to effectively monitor when a surgeon leaves theatre.
” Open source report
23 Dec 2021 Margaret Rose Toye · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Inaccurate recording of MUST malnutrition risk scores View source Failure to assess all patients for malnutrition risk using the MUST score system View source
Responses linked to these concerns
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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
Margaret Rose Toye · 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
Margaret Rose Toye, aged 81, sustained an unwitnessed fall on 10 April 2021, suffered a left neck of femur fracture, underwent surgery on 12 April, and died following a cardiac arrest on 20 April 2021. The principal concern was that she was not assessed for malnutrition using the MUST score system; her records incorrectly recorded a score of 0, and it was considered likely that she would have scored 4, which would have prompted mitigations to maximise her nutritional intake. Contemporary ward audits indicated that one in ten patients were not assessed for malnutrition risk.
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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccurate recording of MUST malnutrition risk scores
Wider context from the report “1. Following admission, Mrs Toye was not assessed for risks of malnutrition by use of the MUST score system. Such an assessment was required for all patients. Erroneously, her notes recorded that she scored 0 on the MUST scale which meant that no other staff members began an assessment throughout her admission . It is likely that during admission Mrs Toye would have scored 4 on a MUST assessment, as such a number of mitigations would have been introduced to maximise her nutritional intake.
2. Contemporary audits of compliance of Must scoring on the ward in question demonstrate that one in ten patients are not being assessed for risks of malnutrition.
” 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 Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess all patients for malnutrition risk using the MUST score system
Wider context from the report “1. Following admission, Mrs Toye was not assessed for risks of malnutrition by use of the MUST score system. Such an assessment was required for all patients. Erroneously, her notes recorded that she scored 0 on the MUST scale which meant that no other staff members began an assessment throughout her admission. It is likely that during admission Mrs Toye would have scored 4 on a MUST assessment, as such a number of mitigations would have been introduced to maximise her nutritional intake.
2. Contemporary audits of compliance of Must scoring on the ward in question demonstrate that one in ten patients are not being assessed for risks of malnutrition .
” 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