28 Apr 2021 Mr Paul Sartori · Prevention of Future Deaths report East London
View report summary
Concerns raised 8 Failure to document the decision-making process and rationale for redirecting patients from A&E View source Insufficient sensitivity of decision-making and risk-scoring tools for aortic dissection View source Failure to record a full set of observations, including a pain score, before diverting patients from A&E View source Insufficient access to CT scanning for suspected aortic dissection View source Failure to recognise and diagnose acute thoracic aortic dissection View source Failure to update streaming guidance in line with relevant learning and guidance View source Failure to embed THINK AORTA learning into emergency department practice at all levels View source Failures in transfer of patients with suspected aortic dissection to specialist centres View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Paul Sartori · 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
Paul Sartori sought emergency medical assistance for chest pain on 24 October 2019, was directed from A&E to an urgent care centre, diagnosed with costochondritis, and later died at home on 27 October 2019 after becoming unresponsive. A post-mortem examination found a ruptured dissecting aortic aneurysm. The report raised systemic concerns about awareness and diagnosis of aortic dissection in emergency departments, including the adequacy of current guidance and risk-scoring tools.
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 document the decision-making process and rationale for redirecting patients from A&E
Wider context from the report “2. The nurse making the decision to re-direct Mr Sartori from A&E did not record a full set of observations, to include a pain score, prior to diverting Mr Sartori from the A & E department. The nurse did not document her decision making process and rationale for redirecting Mr Sartori from 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 Insufficient sensitivity of decision-making and risk-scoring tools for aortic dissection
Wider context from the report “Evidence was heard at the Inquest from an independent cardio thoracic surgeon. During the course of his evidence he stated that in his professional experience, far too many doctors are missing the diagnosis of thoracic aortic dissection. The expert confirmed that the tools to make the diagnosis are readily available in A & E departments. He considered that what is required is a full history and clinical assessment, to include bilateral radial pulses and bilateral blood pressures. If there is a differential between the bilateral pulses and bilateral blood pressures, then a CT scan should be carried out to rule out an aortic dissection.
The expert confirmed that misdiagnosis of aortic dissection is a very common problem.
During the course of the Inquest, information was also provided by the organisation “THINK AORTA”. They stated that:
Our experience is that misdiagnosis of acute aortic dissection is a systemic issue in the NHS which currently leads to many unnecessary deaths. Three main factors underpin the problem of misdiagnosis:
i. Lack of awareness and education
ii. Access to CT scanning
iii. Transfers to specialist centres
The THINK AORTA campaign confirmed that those units that have successfully implemented THINK AORTA to prevent misdiagnosis typically do more than just display the THINK AORTA posters. They embed THINK AORTA in their education and practice by running education sessions two or three times a year and actively questioning patients with chest pain.
Correspondence was also presented at the Inquest from the Aortic Dissection Charitable Trust. They also highlighted that in half of patients presenting with Acute aortic dissection, the diagnosis is not considered and about a third of patients are actively treated for the wrong diagnosis. They estimated that in the UK around 500 patients each year die from acute type A aortic dissection, due to a delayed diagnosis or failure to make the diagnosis. They have questioned whether current decision making tools and risk scoring tools are sensitive enough to:
i. Reliably diagnose or exclude aortic dissection
ii. They confirm their view that education about acute aortic dissection should include all clinicians in the patients’ pathway from first responders to radiologists and they highlight areas that education should focus upon.
The above evidence raised systemic concerns about awareness of aortic dissection in emergency departments and about whether current guidance and risk scoring tools require review and revision to address the widespread misdiagnosis of thoracic aortic dissection.
” 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 full set of observations, including a pain score, before diverting patients from A&E
Wider context from the report “2. The nurse making the decision to re-direct Mr Sartori from A&E did not record a full set of observations, to include a pain score, prior to diverting Mr Sartori from the A & E department . The nurse did not document her decision making process and rationale for redirecting Mr Sartori from 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 Insufficient access to CT scanning for suspected aortic dissection
Wider context from the report “Evidence was heard at the Inquest from an independent cardio thoracic surgeon. During the course of his evidence he stated that in his professional experience, far too many doctors are missing the diagnosis of thoracic aortic dissection. The expert confirmed that the tools to make the diagnosis are readily available in A & E departments. He considered that what is required is a full history and clinical assessment, to include bilateral radial pulses and bilateral blood pressures. If there is a differential between the bilateral pulses and bilateral blood pressures, then a CT scan should be carried out to rule out an aortic dissection.
The expert confirmed that misdiagnosis of aortic dissection is a very common problem.
During the course of the Inquest, information was also provided by the organisation “THINK AORTA”. They stated that:
Our experience is that misdiagnosis of acute aortic dissection is a systemic issue in the NHS which currently leads to many unnecessary deaths. Three main factors underpin the problem of misdiagnosis:
i. Lack of awareness and education
ii. Access to CT scanning
iii. Transfers to specialist centres
The THINK AORTA campaign confirmed that those units that have successfully implemented THINK AORTA to prevent misdiagnosis typically do more than just display the THINK AORTA posters. They embed THINK AORTA in their education and practice by running education sessions two or three times a year and actively questioning patients with chest pain.
Correspondence was also presented at the Inquest from the Aortic Dissection Charitable Trust. They also highlighted that in half of patients presenting with Acute aortic dissection, the diagnosis is not considered and about a third of patients are actively treated for the wrong diagnosis. They estimated that in the UK around 500 patients each year die from acute type A aortic dissection, due to a delayed diagnosis or failure to make the diagnosis. They have questioned whether current decision making tools and risk scoring tools are sensitive enough to:
i. Reliably diagnose or exclude aortic dissection
ii. They confirm their view that education about acute aortic dissection should include all clinicians in the patients’ pathway from first responders to radiologists and they highlight areas that education should focus upon.
The above evidence raised systemic concerns about awareness of aortic dissection in emergency departments and about whether current guidance and risk scoring tools require review and revision to address the widespread misdiagnosis of thoracic aortic dissection.
” 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 recognise and diagnose acute thoracic aortic dissection
Wider context from the report “Evidence was heard at the Inquest from an independent cardio thoracic surgeon. During the course of his evidence he stated that in his professional experience, far too many doctors are missing the diagnosis of thoracic aortic dissection . The expert confirmed that the tools to make the diagnosis are readily available in A & E departments. He considered that what is required is a full history and clinical assessment, to include bilateral radial pulses and bilateral blood pressures. If there is a differential between the bilateral pulses and bilateral blood pressures, then a CT scan should be carried out to rule out an aortic dissection.
The expert confirmed that misdiagnosis of aortic dissection is a very common problem .
During the course of the Inquest, information was also provided by the organisation “THINK AORTA”. They stated that:
Our experience is that misdiagnosis of acute aortic dissection is a systemic issue in the NHS which currently leads to many unnecessary deaths. Three main factors underpin the problem of misdiagnosis:
i. Lack of awareness and education
ii. Access to CT scanning
iii. Transfers to specialist centres
The THINK AORTA campaign confirmed that those units that have successfully implemented THINK AORTA to prevent misdiagnosis typically do more than just display the THINK AORTA posters. They embed THINK AORTA in their education and practice by running education sessions two or three times a year and actively questioning patients with chest pain.
Correspondence was also presented at the Inquest from the Aortic Dissection Charitable Trust. They also highlighted that in half of patients presenting with Acute aortic dissection, the diagnosis is not considered and about a third of patients are actively treated for the wrong diagnosis. They estimated that in the UK around 500 patients each year die from acute type A aortic dissection, due to a delayed diagnosis or failure to make the diagnosis. They have questioned whether current decision making tools and risk scoring tools are sensitive enough to:
i. Reliably diagnose or exclude aortic dissection
ii. They confirm their view that education about acute aortic dissection should include all clinicians in the patients’ pathway from first responders to radiologists and they highlight areas that education should focus upon.
The above evidence raised systemic concerns about awareness of aortic dissection in emergency departments and about whether current guidance and risk scoring tools require review and revision to address the widespread misdiagnosis of thoracic aortic dissection .
” 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 update streaming guidance in line with relevant learning and guidance
Wider context from the report “1. The Inquest heard evidence that the streaming guidance in place for Barts Health A & E staff and NELFT staff had not been updated to take into account the learning from the death of Mr Sartori and to take into account the guidance from the THINK AORTA Campaign (launched in 2016).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to embed THINK AORTA learning into emergency department practice at all levels
Wider context from the report “3. A junior sister who provided evidence at the Inquest was not aware of the THINK AORTA campaign . The Inquest heard that the senior leadership team had recently agreed to embed the THINK AORTA learning into practice at all levels within the emergency department. This learning had not been embedded at the time of the Inquest hearing .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failures in transfer of patients with suspected aortic dissection to specialist centres
Wider context from the report “Evidence was heard at the Inquest from an independent cardio thoracic surgeon. During the course of his evidence he stated that in his professional experience, far too many doctors are missing the diagnosis of thoracic aortic dissection. The expert confirmed that the tools to make the diagnosis are readily available in A & E departments. He considered that what is required is a full history and clinical assessment, to include bilateral radial pulses and bilateral blood pressures. If there is a differential between the bilateral pulses and bilateral blood pressures, then a CT scan should be carried out to rule out an aortic dissection.
The expert confirmed that misdiagnosis of aortic dissection is a very common problem.
During the course of the Inquest, information was also provided by the organisation “THINK AORTA”. They stated that:
Our experience is that misdiagnosis of acute aortic dissection is a systemic issue in the NHS which currently leads to many unnecessary deaths. Three main factors underpin the problem of misdiagnosis:
i. Lack of awareness and education
ii. Access to CT scanning
iii. Transfers to specialist centres
The THINK AORTA campaign confirmed that those units that have successfully implemented THINK AORTA to prevent misdiagnosis typically do more than just display the THINK AORTA posters. They embed THINK AORTA in their education and practice by running education sessions two or three times a year and actively questioning patients with chest pain.
Correspondence was also presented at the Inquest from the Aortic Dissection Charitable Trust. They also highlighted that in half of patients presenting with Acute aortic dissection, the diagnosis is not considered and about a third of patients are actively treated for the wrong diagnosis. They estimated that in the UK around 500 patients each year die from acute type A aortic dissection, due to a delayed diagnosis or failure to make the diagnosis. They have questioned whether current decision making tools and risk scoring tools are sensitive enough to:
i. Reliably diagnose or exclude aortic dissection
ii. They confirm their view that education about acute aortic dissection should include all clinicians in the patients’ pathway from first responders to radiologists and they highlight areas that education should focus upon.
The above evidence raised systemic concerns about awareness of aortic dissection in emergency departments and about whether current guidance and risk scoring tools require review and revision to address the widespread misdiagnosis of thoracic aortic dissection.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete and disseminate a dedicated NELFT learning pack on aortic dissection.
Verbatim wording from the response “Regarding the third matter of concern
As previously described in their letter to you dated 10th May 2021, NELFT have completed and disseminated a dedicated team learning pack on aortic aneurysm dissection, and this will be reinforced at monthly clinician team meetings for NELFT urgent care practitioners.” Source location 2021-0123-Response-from-Royal-London-Hospital-Redacted
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 aortic dissection learning at monthly NELFT urgent care practitioner meetings.
Verbatim wording from the response “Regarding the third matter of concern
As previously described in their letter to you dated 10th May 2021, NELFT have completed and disseminated a dedicated team learning pack on aortic aneurysm dissection, and this will be reinforced at monthly clinician team meetings for NELFT urgent care practitioners.” Source location 2021-0123-Response-from-Royal-London-Hospital-Redacted
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 vital signs, pain score and diversion-decision rationale to ambulance pre-arrival documentation at Whipps Cross, with random manual auditing.
Verbatim wording from the response “Regarding the second matter of concern
Whipps Cross will ensure that the pre-arrival documentation made on CRS when ambulances arrive includes documentation supporting any decision to divert the patient to the Urgent Care Centre. This will include vital signs observations and pain score and will be implemented by 15th June. A process to do this at other Barts Health Emergency Departments is already in place.” Source location 2021-0123-Response-from-Royal-London-Hospital-Redacted
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 Incorporate THINK AORTA as a recurring topic in Barts Health Emergency Department multidisciplinary teaching.
Verbatim wording from the response “All Barts Health Emergency Departments now display “THINK AORTA” posters in prominent positions and incorporate the “THINK AORTA” campaign as a recurring topic of education in departmental multidisciplinary teaching.” Source location 2021-0123-Response-from-Royal-London-Hospital-Redacted
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 and iteratively refresh a local clinical learning piece on aortic dissection alongside scheduled THINK AORTA teaching.
Verbatim wording from the response “A learning piece describing the clinical characteristics of aortic dissection seen in our local population will be shared in departmental teaching during June and this will be refreshed and shared iteratively alongside the scheduled “THINK AORTA” teaching.” Source location 2021-0123-Response-from-Royal-London-Hospital-Redacted
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 and submit joint streaming guidance incorporating THINK AORTA learning for governance approval.
Verbatim wording from the response “NELFT and Barts Health have worked closely to review the current streaming guidance and incorporate the learning from the ‘THINK AORTA’ campaign. The guidance was reviewed on 18th May 2021 by Clinical and Operational leads for NELFT and Barts Health. It has now been submitted to the joint governance and operational group for consideration and sign off at the next session on 8th June 2021.” Source location 2021-0123-Response-from-Royal-London-Hospital-Redacted
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 Barts Health Heart Attack Centre feedback template to prompt exclusion of aortic dissection in non-cardiac chest pain.
Verbatim wording from the response “The Barts Health Heart Attack Centre feedback template has been updated to prompt exclusion of aortic dissection as a cause of non-cardiac chest pain.” Source location 2021-0123-Response-from-Royal-London-Hospital-Redacted
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 documentation processes at other Barts Health Emergency Departments are considered sufficient for recording decisions to divert patients.
Verbatim wording from the response “Regarding the second matter of concern
Whipps Cross will ensure that the pre-arrival documentation made on CRS when ambulances arrive includes documentation supporting any decision to divert the patient to the Urgent Care Centre. This will include vital signs observations and pain score and will be implemented by 15th June. A process to do this at other Barts Health Emergency Departments is already in place.” Source location 2021-0123-Response-from-Royal-London-Hospital-Redacted
Open published response
21 Dec 2020 Evadney Dawkins · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Failure to undertake required renal monitoring View source Failure of governance systems to assess cases as Serious Incidents requiring investigation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Evadney Dawkins · 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
Evadney Dawkins, aged 77, fell at home and was admitted to hospital on 22 July 2018. Renal monitoring planned after assessment was not undertaken for four days, when she was found to have a Grade 3 acute kidney injury; she later suffered a cardiac arrest and was pronounced deceased on 23 August 2018. Concerns also included that the Trust’s governance systems did not identify the case as a Serious Incident requiring investigation for two years.
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 undertake required renal monitoring
Wider context from the report “1. On 22nd July 2018, Mrs Dawkins was assessed to require renal monitoring, incorporating;
a) Regular blood tests
b) A renal ultrasound
c) Fluid intake/output monitoring
The 3 actions were not undertaken for 4 days , after which, it was discovered that the patient had deteriorated and had sustained a Grade 3 acute kidney injury.
2. The Trust’s governance systems did not assess to a case as a Serious Incident requiring investigation for 2 years.
” 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 assess cases as Serious Incidents requiring investigation
Wider context from the report “1. On 22nd July 2018, Mrs Dawkins was assessed to require renal monitoring, incorporating;
a) Regular blood tests
b) A renal ultrasound
c) Fluid intake/output monitoring
The 3 actions were not undertaken for 4 days, after which, it was discovered that the patient had deteriorated and had sustained a Grade 3 acute kidney injury.
2. The Trust’s governance systems did not assess to a case as a Serious Incident requiring investigation for 2 years.
” 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 Use electronic records for integrated patient documentation, automated fluid input/output recording and alerts when safety parameters are breached.
Verbatim wording from the response “Since moving to electronic records system in Autumn 2019 the process for documenting and completing patient records is more accessible and easier to manage, as information is recorded in the same place and legibility is guaranteed. For example, in relation to fluid management charts, input/output can be automatically entered on to the electronic records system, rather than having to rely on paper based charts, contained within the records. This system generates alerts when safe parameters are breached.” Source location 2020-0292-Response-from-Royal-London-Hospital-Redacted
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 Appoint three Medical Examiners to review every death on the site.
Verbatim wording from the response “Additionally we have appointed three Medical Examiners who review every death on the site. These roles are overseen by the Deputy Medical Director which is an additional new post, part of the remit of which is to give greater assurance around patient safety governance. In this way, deaths that do not meet the criteria for a Serious Incident are robustly reviewed. We believe that had these actions been in place at the time of the incident, it is highly likely that it would have been declared as a Serious Incident.” Source location 2020-0292-Response-from-Royal-London-Hospital-Redacted
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 a supported database to monitor acute kidney injury patients and compliance with the bundle.
Verbatim wording from the response “The hospital undertakes frequent audits on nursing documentation, which includes fluid balance, and on NEWS2 for deteriorating patients to gain assurance that care is of a good standard and any deficiencies are addressed. In terms of medical training, recognition and treatment of deteriorating patients is very much the focus of our compulsory simulation days for Foundation and Core Medical trainees. The AKI bundle has been implemented on the site which standardises the response to a patient with AKI and which actions and escalation should be taken following identification. This will” Source location 2020-0292-Response-from-Royal-London-Hospital-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement an acute kidney injury bundle standardising patient response, required actions and escalation.
Verbatim wording from the response “The hospital undertakes frequent audits on nursing documentation, which includes fluid balance, and on NEWS2 for deteriorating patients to gain assurance that care is of a good standard and any deficiencies are addressed. In terms of medical training, recognition and treatment of deteriorating patients is very much the focus of our compulsory simulation days for Foundation and Core Medical trainees. The AKI bundle has been implemented on the site which standardises the response to a patient with AKI and which actions and escalation should be taken following identification. This will” Source location 2020-0292-Response-from-Royal-London-Hospital-Redacted
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 Foundations of Excellence nursing education covering acute kidney injury management across all clinical areas.
Verbatim wording from the response “There have been many changes to address poor handover and lack of knowledge around AKI on the site. Management of AKI is a key component of the Foundations of Excellence program of nursing education which has been rolled out to all areas. However, it was acknowledged that further work needed to be done with the nursing staff to ensure that nurses were sufficiently able to recognise and monitor a renal patient to a high standard. To this end, a second safe nurse role has been established with a particular remit of nursing education, with a focus on deteriorating patients.” Source location 2020-0292-Response-from-Royal-London-Hospital-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a second safe nurse role focused on nursing education and deteriorating patients.
Verbatim wording from the response “There have been many changes to address poor handover and lack of knowledge around AKI on the site. Management of AKI is a key component of the Foundations of Excellence program of nursing education which has been rolled out to all areas. However, it was acknowledged that further work needed to be done with the nursing staff to ensure that nurses were sufficiently able to recognise and monitor a renal patient to a high standard. To this end, a second safe nurse role has been established with a particular remit of nursing education, with a focus on deteriorating patients.” Source location 2020-0292-Response-from-Royal-London-Hospital-Redacted
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 Create a Deputy Medical Director post overseeing Medical Examiners and strengthening patient safety governance assurance.
Verbatim wording from the response “Additionally we have appointed three Medical Examiners who review every death on the site. These roles are overseen by the Deputy Medical Director which is an additional new post, part of the remit of which is to give greater assurance around patient safety governance. In this way, deaths that do not meet the criteria for a Serious Incident are robustly reviewed. We believe that had these actions been in place at the time of the incident, it is highly likely that it would have been declared as a Serious Incident.” Source location 2020-0292-Response-from-Royal-London-Hospital-Redacted
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 nursing documentation, fluid balances and NEWS2 observations to identify and address care deficiencies.
Verbatim wording from the response “The hospital undertakes frequent audits on nursing documentation, which includes fluid balance, and on NEWS2 for deteriorating patients to gain assurance that care is of a good standard and any deficiencies are addressed. In terms of medical training, recognition and treatment of deteriorating patients is very much the focus of our compulsory simulation days for Foundation and Core Medical trainees. The AKI bundle has been implemented on the site which standardises the response to a patient with AKI and which actions and escalation should be taken following identification. This will” Source location 2020-0292-Response-from-Royal-London-Hospital-Redacted
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 unexpected deaths through a multidisciplinary Serious Incident Review meeting, declaring and investigating incidents where appropriate.
Verbatim wording from the response “We recognise that there was a failure to assess and grade Mrs Dawkins’s death correctly as a Serious Incident at the time it happened. We now have an established and robust system in place where unexpected deaths are taken to a Serious Incident Review meeting where they are considered by a multidisciplinary team. Where there is doubt, the hospital errs on the side of declaring the incident as a Serious Incident and investigating as such, de-escalating as appropriate.” Source location 2020-0292-Response-from-Royal-London-Hospital-Redacted
Open published response
2 Dec 2020 Ivan Merryfield O’Neill · Prevention of Future Deaths report East London
View report summary
Concerns raised 4 Limited physiological reserve increasing risk of rapid loss of consciousness following bleeding View source Restlessness during dialysis increasing risk of needle dislodgement View source Failure of dialysis equipment alarms to promptly alert staff to bleeding View source Failure to position dialysis patients within a clear line of sight from the nurses station View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Ivan Merryfield O’Neill · 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
Ivan Merryfield O’Neill bled to death during a dialysis appointment after a venous needle became dislodged from his arteriovenous fistula. Concerns included his restlessness and frailty, his position outside a clear line of sight from the nurses’ station, and an alarm that did not promptly alert staff to the bleed.
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 Limited physiological reserve increasing risk of rapid loss of consciousness following bleeding
Wider context from the report “2. Mr O’Neill was a frail patient with little reserve and would be more likely to swiftly lose consciousness following a bleed .
” 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 Restlessness during dialysis increasing risk of needle dislodgement
Wider context from the report “1. Mr O’Neill was known to be a restless patient during a dialysis session . This factor must have increased the risk of needle dislodgement .
” 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 dialysis equipment alarms to promptly alert staff to bleeding
Wider context from the report “4. The automatic alarm triggered by the dialysis equipment was insufficiently sensitive to promptly alert staff to a bleed until between 200 – 2000 mls of blood had already been lost .
” 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 position dialysis patients within a clear line of sight from the nurses station
Wider context from the report “3. Mr O’Neill was placed in a position which was outside of a clear line of sight from the nurses station .
” Open source report
3 Nov 2020 Clara Iris Moniatis · Prevention of Future Deaths report Essex
View report summary
Concerns raised 2 Delays in review of chest x-ray imaging View source Lack of a system ensuring prompt clinical review after PEWS alerts View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Clara Iris Moniatis · 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
Clara Iris Moniatis had been unwell for several days and died at Whipps Cross Hospital on 5 May 2019 despite medical treatment; the stated cause of death was previously undiagnosed dilated cardiomyopathy. The concerns related to waiting times for reviewing chest X-ray imaging and the need for a system ensuring that a PEWS alert prompts a timely clinical 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 Delays in review of chest x-ray imaging
Wider context from the report “1. The matter of waiting times from chest x-ray to the review of the imaging
” 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 ensuring prompt clinical review after PEWS alerts
Wider context from the report “2. The matter of the need for a system whereby a PEWS alert leads to a prompt clinical review
” 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 Share learning about early senior review of deteriorating patients and PEWS escalation protocols widely among clinical staff.
Verbatim wording from the response “Following a thorough review of our own investigation findings and the views of the Coroner’s expert witness, and taking into account that Clara was seen by a senior specialist doctor within 20 minutes of her PEWS increase, we believe we could have done nothing which would have prevented Clara’s sad outcome. However, this has reaffirmed the critical importance of early senior review of deteriorating patients, following national guidelines on the escalation protocol for PEWS, and we have shared the learning widely among our clinical staff.” Source location 2020-0221-Response-from-Barts-Health-NHS-Trust.pdf
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 No additional intervention would have prevented the outcome, given the senior specialist review within 20 minutes of the PEWS increase.
Verbatim wording from the response “Following a thorough review of our own investigation findings and the views of the Coroner’s expert witness, and taking into account that Clara was seen by a senior specialist doctor within 20 minutes of her PEWS increase, we believe we could have done nothing which would have prevented Clara’s sad outcome. However, this has reaffirmed the critical importance of early senior review of deteriorating patients, following national guidelines on the escalation protocol for PEWS, and we have shared the learning widely among our clinical staff.” Source location 2020-0221-Response-from-Barts-Health-NHS-Trust.pdf
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 Documented chest X-ray review timings represent maximum intervals because notes are often recorded retrospectively in the busy emergency department.
Verbatim wording from the response “We have previously noted that the documented timings of x-ray review represent a maximum time, as notes are often made in retrospect within a busy emergency department.” Source location 2020-0221-Response-from-Barts-Health-NHS-Trust.pdf
Open published response
11 Aug 2020 Moses Victor Boardman · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 6 Failure to commence CPR when a reversible cause for collapse overrides a DNAR order View source Failure of a commissioned care provider to escalate inability to reach a patient for care visits View source Absence of a clear computerised record explaining a change of address in the departure lounge View source Lack of a clear safeguard ensuring vulnerable patients are discharged to the correct address View source Failure to properly monitor patients assessed as fed at risk View source Failure of transport staff to properly assess venue suitability 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
Moses Victor Boardman · 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
Moses Victor Boardman, an elderly and frail man, was mistakenly discharged to his home instead of sheltered accommodation, where he was found without heating, light or food and subsequently readmitted to hospital after a further cerebrovascular accident. While assessed as being at risk of aspiration and requiring supervised feeding, he was later found eating a whole fruit unsupervised, suffered a choking incident, and died at 04.48. The substantive concerns included discharge and transport safeguards, failure to escalate missed care visits, monitoring of patients fed at risk, and the response to a potential reversible cause of collapse when a DNACPR order was in place.
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 commence CPR when a reversible cause for collapse overrides a DNAR order
Wider context from the report “6. The RLH failure to commence CPR when a potential reversible cause for collapse existed that would override the effect of the DNAR order .
” 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 a commissioned care provider to escalate inability to reach a patient for care visits
Wider context from the report “4. The responsiveness of the care provider commissioned by LBTH to escalate the fact that they had been unable to reach Mr Boardman for his first 3 care visits .
” 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 Absence of a clear computerised record explaining a change of address in the departure lounge
Wider context from the report “1. The absence of a clear computerised record in the RLH departure lounge explaining the change of address.
” 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 clear safeguard ensuring vulnerable patients are discharged to the correct address
Wider context from the report “2. The lack of a clear safeguard to ensure that a vulnerable patient is discharged to the correct address .
” 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 properly monitor patients assessed as fed at risk
Wider context from the report “5. The proper monitoring of patients on RLH ward 14F who have been assessed as being “fed at risk” . Specifically, why was a vulnerable patient left with unsuitable foods within his reach .
” 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 transport staff to properly assess venue suitability
Wider context from the report “3. The failure of RLH transport staff to properly assess the suitability of the venue that a patient is being taken to.
” 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 Conduct departure-lounge documentation audits in line with Trust practice.
Verbatim wording from the response “At the inquest you asked for evidence of this change in documentation and whether any audits had taken place. As an action in light of this query the departure lounge will now complete documentation audits in line with trust practice for clinical areas to provide assurance that this is being completed.” Source location 2020-0160-Response-from-Barts-Health-NHS-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require discharge-lounge staff to confirm transport destinations, escalate discrepancies, and record the confirmation in electronic medical records.
Verbatim wording from the response “2. The lack of a clear safeguard to ensure that a vulnerable patient is discharge to the correct address.
Again, action was taken for this concern at the time of the SI Investigation. The departure lounge clarified in their SOP that when a patient is discharged via hospital transport the Discharge Lounge staff will confirm with the Patient Transport Service driver the location and agreed destination for the patient. Any discrepancy must be escalated to the ward area for confirmation and Senior Clinical Site Manager if this discrepancy persists. Again, as per point 1, the staff will document this within the patients electronic medical records.” Source location 2020-0160-Response-from-Barts-Health-NHS-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require departure-lounge staff to document address changes in patients’ electronic records under a signed-off standard operating procedure.
Verbatim wording from the response “1. The absence of a clear computerised record in the RLH departure lounge explaining the change of address.
This issue was identified as part of the trusts Serious Incident (SI) investigation and action was taken at the time. The departure lounge changed its practice to ensure that the staff document in the patients electronic record in line with trust practice. Confirmation of this has been detailed within the departments most recent version of the Standard Operating Procedure (SOP). At the inquest you were shown this SOP in draft form but I can update you now to say that it has now been signed off by the Royal London Hospital’s Executive Board.” Source location 2020-0160-Response-from-Barts-Health-NHS-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review transport safeguarding processes and amend them according to the review findings.
Verbatim wording from the response “As an action the Associate Director of Transport has arranged to review the current safeguarding processes in place and this process will be amended according to their findings.” Source location 2020-0160-Response-from-Barts-Health-NHS-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust disputes that an immediate reversible cause existed to override the DNAR order, concluding that no airway obstruction was present.
Verbatim wording from the response “It’s clear from staff statements that Mr Boardman had taken a bite out of the kiwi fruit before it was removed at 2000. At 0200 he is heard coughing and when the nurse attends she finds him unresponsive. Although he has a DNR order the cardiac arrest team is called. They arrive and find him unresponsive with agonal breathing. This type of breathing would not occur with any form of upper airway obstruction; it was also six hours after he had taken a bite of the kiwi fruit. This related to poor blood flow to the brain, fitting with the description of him having an impalpable pulse. In view of no immediate reversible cause, such as an airway obstruction the DNR order was followed and the gentleman passed away peacefully two hours later.” Source location 2020-0160-Response-from-Barts-Health-NHS-Trust_Redacted.pdf
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 Responsibility for the commissioned care provider’s failure to escalate missed visits rests with Tower Hamlets Local Authority.
Verbatim wording from the response “4. The responsiveness of the care provider commissioned by LBTH to escalate the fact that they had been unable to reach Mr Boardman for his first 3 visits
This is a matter for LBTH to respond to” Source location 2020-0160-Response-from-Barts-Health-NHS-Trust_Redacted.pdf
Open published response
2 Mar 2020 Mrs Ibiyemi Ereohah · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Failure to ensure timely consultant reviews View source Insufficient gynae-oncology consultant cover View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mrs Ibiyemi Ereohah · 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 Ibiyemi Ereohah attended hospital with abdominal pain and anaemia, and investigations concerning a possible sarcoma were followed by delays and deficiencies in assessment and surgical planning. She underwent a hysterectomy on 30 August 2018 and was subsequently diagnosed with a high-grade uterine sarcoma; she died from metastatic leiomyosarcoma on 17 September 2018. The substantive concerns included inadequate gynae-oncology consultant cover and a delayed consultant review of her fitness for surgery.
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 ensure timely consultant reviews
Wider context from the report “2. Mrs Ereohah was deemed unfit for surgery by a clinical nurse specialist on the 16th February 2018. The nurse requested a consultant review which should have taken place within 3-5 weeks. It did not take place until 16 weeks later. The Inquest heard evidence that there was no system in place to ensure that all consultant reviews were carried out within a timely manner .
” 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 gynae-oncology consultant cover
Wider context from the report “1. Many of the concerns arising in this case were considered to be due to an insufficiency of gynae-oncology consultant cover at Newham University hospital . The lack of adequate Consultant cover was deemed to have contributed to the lack of advocacy at the MDT meeting; the inability to challenge the MDT conclusion and the lack of Consultant overview of the recurrent admissions . In July 2019, the Trust agreed two key actions to address this deficiency:
• Clinical Leads at the RLH and NUH to review gynaecological oncology staffing and job planning, to ensure adequate administration time; cover when on leave/programmed for other duties, such as hot weeks.
• There should be an urgent organisational development/service level review of the NUH gynae-oncology team that is independent of the site.
As at the date of the Inquest, neither of these necessary actions had been completed.
” Open source report
20 Dec 2019 Keith HILL · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 6 Failure to provide adequate senior specialist support to junior medical staff View source Failure to ensure proper scrutiny of prescriptions during night-time care View source Failure to document treatment-plan changes and prescribing decisions View source Failure to ensure communication between interventional radiology and hepatology specialists View source Unavailability of a specialist hepatology pharmacist for advice View source Failure to maintain accurate records of specialist decision making 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
Keith HILL · 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
Keith Hill was admitted with biliary sepsis and underwent a liver biopsy, after which he developed bleeding requiring surgery and later suffered bowel haemorrhage. The report identified concerns about communication between specialists, inadequate medical records, and insufficient support and scrutiny around the prescription and dispensing of micafungin.
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 provide adequate senior specialist support to junior medical staff
Wider context from the report “3. The junior pharmacist charged with dispensing the micafungin on the evening of 25 June recognised its toxicity to the liver and could not see from the medical record that Mr Hill’s liver function tests and hepatitis had been taken into account in the prescription.
The last relevant entry in the medical record indicated that the micafungin should be held off.
He sought senior guidance. However, there was no specialist hepatology pharmacist on the list of available contacts.
Recognising he was outside his expertise, he contacted an intensive care specialist pharmacist, the on call microbiologist and the medical doctor looking after Mr Hill. However, no decision was made regarding the micafungin and so it was simply not given.
A professor of hepatology was on call and knew Mr Hill’s situation well, but he was not contacted by the ward doctor (or by the microbiologist or a senior pharmacist).
Despite improvements to the availability of senior pharmacists on call at the Royal London Hospital, concern remains about night time care and proper scrutiny of prescriptions. Junior medical staff do not appear to be sufficiently supported in this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure proper scrutiny of prescriptions during night-time care
Wider context from the report “3. The junior pharmacist charged with dispensing the micafungin on the evening of 25 June recognised its toxicity to the liver and could not see from the medical record that Mr Hill’s liver function tests and hepatitis had been taken into account in the prescription .
The last relevant entry in the medical record indicated that the micafungin should be held off.
He sought senior guidance. However, there was no specialist hepatology pharmacist on the list of available contacts.
Recognising he was outside his expertise, he contacted an intensive care specialist pharmacist, the on call microbiologist and the medical doctor looking after Mr Hill. However, no decision was made regarding the micafungin and so it was simply not given.
A professor of hepatology was on call and knew Mr Hill’s situation well, but he was not contacted by the ward doctor (or by the microbiologist or a senior pharmacist).
Despite improvements to the availability of senior pharmacists on call at the Royal London Hospital, concern remains about night time care and proper scrutiny of prescriptions . Junior medical staff do not appear to be sufficiently supported in this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document treatment-plan changes and prescribing decisions
Wider context from the report “2. Mr Hill’s medical records were at times inadequate . The microbiologists thought that the junior hepatologists were making a record and vice versa. In the event, neither did. Most specifically, following the repeated advice of the microbiologists, the decision to change the plan and to prescribe micafungin on 25 June was not documented , it was simply written up on the prescription chart.
” 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 communication between interventional radiology and hepatology specialists
Wider context from the report “1. When the plan changed and the transjugular liver biopsy became a percutaneous one, there was no communication between the interventional radiologist and the hepatologists . Even if it had not changed the plan, Mr Hill’s management would have benefited from a robust discussion between the specialists in these two fields , and a more accurate record of the decision making.
” 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 Unavailability of a specialist hepatology pharmacist for advice
Wider context from the report “3. The junior pharmacist charged with dispensing the micafungin on the evening of 25 June recognised its toxicity to the liver and could not see from the medical record that Mr Hill’s liver function tests and hepatitis had been taken into account in the prescription.
The last relevant entry in the medical record indicated that the micafungin should be held off.
He sought senior guidance. However, there was no specialist hepatology pharmacist on the list of available contacts .
Recognising he was outside his expertise, he contacted an intensive care specialist pharmacist, the on call microbiologist and the medical doctor looking after Mr Hill. However, no decision was made regarding the micafungin and so it was simply not given.
A professor of hepatology was on call and knew Mr Hill’s situation well, but he was not contacted by the ward doctor (or by the microbiologist or a senior pharmacist).
Despite improvements to the availability of senior pharmacists on call at the Royal London Hospital, concern remains about night time care and proper scrutiny of prescriptions. Junior medical staff do not appear to be sufficiently supported in this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate records of specialist decision making
Wider context from the report “1. When the plan changed and the transjugular liver biopsy became a percutaneous one, there was no communication between the interventional radiologist and the hepatologists. Even if it had not changed the plan, Mr Hill’s management would have benefited from a robust discussion between the specialists in these two fields, and a more accurate record of the decision making .
” 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 junior pharmacists with an accountable senior pharmacist available each evening through a published out-of-hours rota for advice, resolution and escalation of complex issues.
Verbatim wording from the response “Since October 2019, the Pharmacy Department has instituted a positive change in the out of hours clinical support provided to junior pharmacists on-call. There is now a published rota, where each evening there is an accountable senior pharmacist off-site who is available to discuss and provide advice and resolution for any complex patients or issues. This includes advising on the need for specialist clinical advice and escalating where necessary. This support ensures our junior pharmacists and patients benefit from expert senior clinical pharmacy advice out of hours as well as during the normal working day. Pharmacists have reported in their monthly meetings that they now feel very well supported and having a named point of contact out of hours provides much needed discussion and advice when necessary.” Source location 2019-0446-Response-from-Barts-NHS-Trust-R
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 Repeat consultant-support and escalation information during induction training for new junior doctors.
Verbatim wording from the response “Following this case, the hepatology team have reiterated to the junior doctors on the team the availability of consultant support and have ensured that the switchboard contact details and ward 'white board' is up-to-date. This will also be repeated during the induction training of new medical juniors and the consultants are stressing to their trainees the importance of escalation.” Source location 2019-0446-Response-from-Barts-NHS-Trust-R
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 note keeping regularly at monthly morbidity and mortality meetings to drive and maintain improvement.
Verbatim wording from the response “Note keeping has been reviewed by the consultant body and there has been agreement that the quality of note keeping must always meet the standards of best practice. There will be regular audits of note keeping at the monthly M&M meeting to drive and maintain improvement.” Source location 2019-0446-Response-from-Barts-NHS-Trust-R
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 regular documented MDT discussions between medical teams and interventional radiologists, including discussions for non-elective patients outside formal MDT meetings.
Verbatim wording from the response “This case has led to a review of how decisions are discussed and documented between the treating team and the interventional radiology team. There are regular and documented discussions in the MDT meeting between the medical teams and the interventional radiologists; in addition there are conversations between referring teams and the interventional radiologists if non-elective patients are being treated without having been through a formal MDT discussion.
In this context it is agreed between all clinical teams that at the time of the procedure the interventional radiologists will decide as to how to proceed based on their clinical knowledge, experience and the clinical situation at that point. Further conversations with the referring team at this point and in this case would not have changed the procedure performed.” Source location 2019-0446-Response-from-Barts-NHS-Trust-R
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 Reiterate consultant support and escalation expectations to junior hepatology doctors, and update switchboard and ward whiteboard contact details.
Verbatim wording from the response “Following this case, the hepatology team have reiterated to the junior doctors on the team the availability of consultant support and have ensured that the switchboard contact details and ward 'white board' is up-to-date. This will also be repeated during the induction training of new medical juniors and the consultants are stressing to their trainees the importance of escalation.” Source location 2019-0446-Response-from-Barts-NHS-Trust-R
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 requirements for significant clinical decisions to be documented in patient records and for clinical notes to meet best-practice standards.
Verbatim wording from the response “However, if the planned procedure proves impossible, or by the time the patient arrives in the IR theatre the patient has had a significant change in condition, the radiologist would contact the referring team. All significant decisions should be documented in the patient record. The importance of this has been reinforced.” Source location 2019-0446-Response-from-Barts-NHS-Trust-R
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 Further discussions with the referring team at the procedure stage would not have changed the procedure performed.
Verbatim wording from the response “This case has led to a review of how decisions are discussed and documented between the treating team and the interventional radiology team. There are regular and documented discussions in the MDT meeting between the medical teams and the interventional radiologists; in addition there are conversations between referring teams and the interventional radiologists if non-elective patients are being treated without having been through a formal MDT discussion.
In this context it is agreed between all clinical teams that at the time of the procedure the interventional radiologists will decide as to how to proceed based on their clinical knowledge, experience and the clinical situation at that point. Further conversations with the referring team at this point and in this case would not have changed the procedure performed.” Source location 2019-0446-Response-from-Barts-NHS-Trust-R
Open published response
23 Oct 2019 Kenneth John Daly · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Lack of tailored written guidance on pain relief and other medications View source Unclear prescribing advice for concurrent pain-relieving medications View source Lack of written advice on the risks of combining multiple opioids View source Failure to seek clarification of unclear prescribing advice View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Kenneth John Daly · 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 John Daly, who had chronic pain and anxiety and was prescribed multiple medications, was found dead at home on 4 December 2018. The inquest concluded that his death was drug related, involving multi-drug toxicity, after he overdosed on Morphine, Dihydrocodeine and Codeine alongside Pregabalin and benzodiazepine medication. Concerns included unclear guidance about using multiple opioid medications together and the absence of tailored written advice for Mr Daly.
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 tailored written guidance on pain relief and other medications
Wider context from the report “1) In oral evidence, the Consultant stated that no other opioids were to be taken once Morphine Sulphate and Co-Codamol had been prescribed but that prescribing of Pregabalin could continue. She set out her advice in a letter to Mr Daly’s GP dated 11 July 2018. The letter clearly stated that Fentanyl and Tapentadol should be stopped and Morphine sulphate (MST) 60mg started. The advice regarding the prescribing of pain relieving medications other than Fentanyl and Tapentadol is less clear. In relation to Dihydrocodeine and Tramadol it is stated that “He can continue using the Dihydrocodeine and very rarely Tramadol until he sees you for his next prescription. Together with the MST, I would recommend to allow him Co-Codamol 30/500mg 2 tablets up to four times a day...”. Following receipt of the letter, Tramadol and Dihydrocodeine continued to be issued by the GP practice albeit at lower quantities than previously prescribed. The GP did not seek any further guidance regarding the advice given in the letter of 11 July 2018 from the Consultant.
2) Mr Daly was a patient that was known to adjust his pain medication without seeking guidance from his GP. Whilst Mr Daly was copied in to the letter sent to his GP on 11 July 2018, he was not given any written guidance regarding his pain relief and the use of other medications (such as benzodiazepines) that was tailored to his needs as a patient.
Specifically, he was not given any written advice regarding the risks of using multiple opioid medications in combination.
” 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 Unclear prescribing advice for concurrent pain-relieving medications
Wider context from the report “1) In oral evidence, the Consultant stated that no other opioids were to be taken once Morphine Sulphate and Co-Codamol had been prescribed but that prescribing of Pregabalin could continue. She set out her advice in a letter to Mr Daly’s GP dated 11 July 2018. The letter clearly stated that Fentanyl and Tapentadol should be stopped and Morphine sulphate (MST) 60mg started. The advice regarding the prescribing of pain relieving medications other than Fentanyl and Tapentadol is less clear. In relation to Dihydrocodeine and Tramadol it is stated that “He can continue using the Dihydrocodeine and very rarely Tramadol until he sees you for his next prescription. Together with the MST, I would recommend to allow him Co-Codamol 30/500mg 2 tablets up to four times a day...”. Following receipt of the letter, Tramadol and Dihydrocodeine continued to be issued by the GP practice albeit at lower quantities than previously prescribed. The GP did not seek any further guidance regarding the advice given in the letter of 11 July 2018 from the Consultant.
2) Mr Daly was a patient that was known to adjust his pain medication without seeking guidance from his GP. Whilst Mr Daly was copied in to the letter sent to his GP on 11 July 2018, he was not given any written guidance regarding his pain relief and the use of other medications (such as benzodiazepines) that was tailored to his needs as a patient.
Specifically, he was not given any written advice regarding the risks of using multiple opioid medications in combination.
” 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 written advice on the risks of combining multiple opioids
Wider context from the report “1) In oral evidence, the Consultant stated that no other opioids were to be taken once Morphine Sulphate and Co-Codamol had been prescribed but that prescribing of Pregabalin could continue. She set out her advice in a letter to Mr Daly’s GP dated 11 July 2018. The letter clearly stated that Fentanyl and Tapentadol should be stopped and Morphine sulphate (MST) 60mg started. The advice regarding the prescribing of pain relieving medications other than Fentanyl and Tapentadol is less clear. In relation to Dihydrocodeine and Tramadol it is stated that “He can continue using the Dihydrocodeine and very rarely Tramadol until he sees you for his next prescription. Together with the MST, I would recommend to allow him Co-Codamol 30/500mg 2 tablets up to four times a day...”. Following receipt of the letter, Tramadol and Dihydrocodeine continued to be issued by the GP practice albeit at lower quantities than previously prescribed. The GP did not seek any further guidance regarding the advice given in the letter of 11 July 2018 from the Consultant.
2) Mr Daly was a patient that was known to adjust his pain medication without seeking guidance from his GP. Whilst Mr Daly was copied in to the letter sent to his GP on 11 July 2018, he was not given any written guidance regarding his pain relief and the use of other medications (such as benzodiazepines) that was tailored to his needs as a patient.
Specifically, he was not given any written advice regarding the risks of using multiple opioid medications in combination.
” 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 seek clarification of unclear prescribing advice
Wider context from the report “1) In oral evidence, the Consultant stated that no other opioids were to be taken once Morphine Sulphate and Co-Codamol had been prescribed but that prescribing of Pregabalin could continue. She set out her advice in a letter to Mr Daly’s GP dated 11 July 2018. The letter clearly stated that Fentanyl and Tapentadol should be stopped and Morphine sulphate (MST) 60mg started. The advice regarding the prescribing of pain relieving medications other than Fentanyl and Tapentadol is less clear. In relation to Dihydrocodeine and Tramadol it is stated that “He can continue using the Dihydrocodeine and very rarely Tramadol until he sees you for his next prescription. Together with the MST, I would recommend to allow him Co-Codamol 30/500mg 2 tablets up to four times a day...”. Following receipt of the letter, Tramadol and Dihydrocodeine continued to be issued by the GP practice albeit at lower quantities than previously prescribed. The GP did not seek any further guidance regarding the advice given in the letter of 11 July 2018 from the Consultant.
2) Mr Daly was a patient that was known to adjust his pain medication without seeking guidance from his GP. Whilst Mr Daly was copied in to the letter sent to his GP on 11 July 2018, he was not given any written guidance regarding his pain relief and the use of other medications (such as benzodiazepines) that was tailored to his needs as a patient.
Specifically, he was not given any written advice regarding the risks of using multiple opioid medications in combination.
” Open source report
16 Jun 2019 Shahida Begum · Prevention of Future Deaths report East London
View report summary
Concerns raised 1 Failure to make patient destination decisions using clinical observations before streamer assessment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Shahida Begum · 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
Shahida Begum became unwell on 3 July 2018, attended an out-of-hours GP and then A&E, and was later directed back to a GP despite observations that should have triggered further assessment. She collapsed on 10 July 2018, was found to have sepsis, and died in hospital from an invasive group A streptococcal infection. The principal concern was that clinical streaming at Newham University Hospital took place before clinical observations were available, contributing to decisions about directing patients away from A&E.
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 patient destination decisions using clinical observations before streamer assessment
Wider context from the report “The current system in place at Newham University Hospital is that a clinical streamer will make a decision about the destination of the patient (GP clinic; urgent treatment centre or A&E), before clinical observations are taken by the triage nurse . The decision is based upon an “eyeballing” check of the patient and a brief history from the patient . It was considered by myself, (as Coroner), by an independent emergency medicine expert and a senior doctor from Newham University Hospital that a safer system would be for the streamer to have the clinical observations available to them before they see the patient .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require vital signs to be recorded and available to streamers before streaming decisions are made.
Verbatim wording from the response “Since this incident we have changed our procedures so that the vital sign records are taken and made available to the streamer before the streaming decision is made. We have also provided additional training for streamers and will continue to do this on an ongoing basis to ensure streamers are aware of the importance of abnormal clinical observations when assessing the suitability of patients for assessment in the urgent treatment centre.” Source location 2019-0199-Response-by-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 Provide ongoing training to streamers on recognising abnormal observations when assessing urgent treatment centre suitability.
Verbatim wording from the response “Since this incident we have changed our procedures so that the vital sign records are taken and made available to the streamer before the streaming decision is made. We have also provided additional training for streamers and will continue to do this on an ongoing basis to ensure streamers are aware of the importance of abnormal clinical observations when assessing the suitability of patients for assessment in the urgent treatment centre.” Source location 2019-0199-Response-by-Barts-Health-NHS-Trust
Open published response
29 Apr 2019 Steffan Kuenzel · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Lack of specific advice for people independently reducing alcohol consumption View source Failure to provide information about alcohol withdrawal signs and symptoms requiring urgent medical treatment 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
Steffan Kuenzel · 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
Steffan Kuenzel, who had longstanding alcohol-related problems and previous withdrawal seizures, reduced his alcohol consumption and became unwell before losing consciousness and dying in hospital on 11 November 2018. The inquest concluded that his death was alcohol related, with a cardiac arrest following a 10-day period of alcohol withdrawal. The concerns were that he was advised to reduce his drinking without specific guidance on how to do so, and that he and his partner were unaware of other alcohol-withdrawal symptoms requiring urgent medical treatment besides seizures.
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 specific advice for people independently reducing alcohol consumption
Wider context from the report “1) The decline in Mr Kuenzel’s health appears to coincide with the reduction from 750 ml vodka per day to 375 ml. Mr Kuenzel had attended hospital with alcohol withdrawal related seizures on a number of occasions. He was advised to gradually reduce his drinking but not given any specific advice as to how this should be done. Whilst alcohol reduction is most safely undertaken with the support of specialist agencies, there will be some people who present at hospital with serious alcohol withdrawal related problems that will not engage with services. Those individuals may develop withdrawal related problems through deciding to reduce their alcohol consumption independently.
” 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 information about alcohol withdrawal signs and symptoms requiring urgent medical treatment
Wider context from the report “2) The deterioration in Mr Kuenzel’s health from late October 2018 may be attributable to alcohol withdrawal. Mr Kuenzel and his partner knew that he needed to seek medical attention if he had a seizure but did not know of any other signs or symptoms of alcohol withdrawal which would require urgent medical treatment.
” Open source report
7 Mar 2019 CHAND ALI · Prevention of Future Deaths report City of London
View report summary
Concerns raised 3 Failure to require individualized risk-benefit justification for cyclizine prescribing in severe heart failure View source Lack of monitoring and analysis of deaths following recent cyclizine use View source Lack of comprehensive review of available alternative antiemetics View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
CHAND ALI · 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
Chand Ali, a 78-year-old man with severe end-stage heart failure and diabetes, was admitted to hospital with fluid overload and decompensated heart failure and died later that day. Cyclizine was administered intravenously despite cautions concerning its use in severe heart failure. Concerns included its routine use without individual risk-benefit assessment, the lack of monitoring of deaths following recent cyclizine use, and the absence of a comprehensive review of alternative antiemetics.
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 require individualized risk-benefit justification for cyclizine prescribing in severe heart failure
Wider context from the report “As stated above, cyclizine is an antiemetic which, according to the British National Formula, must be used with caution for patients suffering severe heart failure, especially if it is administered intra-venously.
The evidence revealed that cyclizine is administered to heart failure patients at St. Bartholomew’s Hospital, including those suffering severe heart failure, as the routine or standard antiemetic and without consideration of its likely effect on the individual patient in question . There is no system in place in the hospital requiring the prescriber to balance any risk to the patient arising from the use of cyclizine against the patient’s clinical need for it, in order to justify its prescription .
Further, whilst it was said that the Hospital was not aware of any pattern or trend of deaths following the administration of cyclizine, it was accepted that the actual incidence of such deaths was not, in fact, known. It was accepted that monitoring and analysis of all deaths following the recent use of cyclizine would be needed in order to establish a reliable picture.
It was also apparent from the evidence that there had been no comprehensive review of other available antiemetics in order to explore whether there exists and effective alternative antiemetic which is not subject to a caution in the British National Formula as to its use.
” 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 and analysis of deaths following recent cyclizine use
Wider context from the report “As stated above, cyclizine is an antiemetic which, according to the British National Formula, must be used with caution for patients suffering severe heart failure, especially if it is administered intra-venously.
The evidence revealed that cyclizine is administered to heart failure patients at St. Bartholomew’s Hospital, including those suffering severe heart failure, as the routine or standard antiemetic and without consideration of its likely effect on the individual patient in question. There is no system in place in the hospital requiring the prescriber to balance any risk to the patient arising from the use of cyclizine against the patient’s clinical need for it, in order to justify its prescription.
Further, whilst it was said that the Hospital was not aware of any pattern or trend of deaths following the administration of cyclizine, it was accepted that the actual incidence of such deaths was not, in fact, known . It was accepted that monitoring and analysis of all deaths following the recent use of cyclizine would be needed in order to establish a reliable picture .
It was also apparent from the evidence that there had been no comprehensive review of other available antiemetics in order to explore whether there exists and effective alternative antiemetic which is not subject to a caution in the British National Formula as to its use.
” 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 comprehensive review of available alternative antiemetics
Wider context from the report “As stated above, cyclizine is an antiemetic which, according to the British National Formula, must be used with caution for patients suffering severe heart failure, especially if it is administered intra-venously.
The evidence revealed that cyclizine is administered to heart failure patients at St. Bartholomew’s Hospital, including those suffering severe heart failure, as the routine or standard antiemetic and without consideration of its likely effect on the individual patient in question. There is no system in place in the hospital requiring the prescriber to balance any risk to the patient arising from the use of cyclizine against the patient’s clinical need for it, in order to justify its prescription.
Further, whilst it was said that the Hospital was not aware of any pattern or trend of deaths following the administration of cyclizine, it was accepted that the actual incidence of such deaths was not, in fact, known. It was accepted that monitoring and analysis of all deaths following the recent use of cyclizine would be needed in order to establish a reliable picture.
It was also apparent from the evidence that there had been no comprehensive review of other available antiemetics in order to explore whether there exists and effective alternative antiemetic which is not subject to a caution in the British National Formula as to its use .
” 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 evidence for cyclizine use in severe heart failure and assess available alternative anti-emetics.
Verbatim wording from the response “In response to this regulation 28 report our lead pharmacist for Barts Heart Centre, ████████, has undertaken an extensive review of the evidence available to support the caution highlighted in the British National Formulary for use of Cyclizine in patients with severe heart failure along with consideration of alternative anti-emetics that are available for our use.” Source location 2019-0085-Response-by-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 No suitable alternative anti-emetic is available because the alternatives considered also carry cardiac cautions.
Verbatim wording from the response “I have enclosed ████████ report but in summary, he has identified that the evidence base for this caution is very limited and its validity to clinical practice remains questionable. He has considered the 3 alternative anti-emetic drugs commonly used in our hospital but each of these come with their own cardiac cautions and do not offer a suitable alternative to the use of cyclizine.” Source location 2019-0085-Response-by-Barts-Health-NHS-Trust
Open published response
22 Feb 2019 Gabriele Kreichgauer · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Failure of clinical decision support to distinguish infected cat bite from cat scratch fever View source Lack of a feedback mechanism within clinical decision support View source Failure to complete a final check of considered treatment and treatment given 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
Gabriele Kreichgauer · 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
Gabriele Kreichgauer attended hospital with an infected cat bite, but was discharged without receiving the intended antibiotics and later developed sepsis and died. Concerns included the absence of a final treatment check and the use of an internet resource that led to an incorrect diagnosis and potentially ineffective treatment; the resource also lacked an apparent feedback mechanism for clinicians to raise concerns.
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 clinical decision support to distinguish infected cat bite from cat scratch fever
Wider context from the report “(2) The junior doctor who saw Ms Kreichgauer used an internet resource called “Uptodate”. The evidence was that the Trust supplies the subscription for this. He searched under the phrase “cat bite” and was directed to a diagnosis of cat scratch fever . On this basis he planned to prescribe azithromycin. In fact, the correct diagnosis was that Ms Kreichgauer had an infected cat bite; the infective organism for this is different to the organism causing cat scratch fever; and the appropriate treatment is different. Even if she had been given antibiotics it is therefore likely that these would not have been effective.
At the inquest the clinicians accepted that it would be helpful for there to be a warning on Uptodate pointing out the need to consider the possibility of infected cat bite (and the important difference between this and cat scratch fever) when searching under either term (“cat bite” or “cat scratch”) . It was accepted that the Trust should be in a position to communicate with Uptodate to point out this 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 a feedback mechanism within clinical decision support
Wider context from the report “(3) There does not appear to be a feedback mechanism within Uptodate to allow clinicians to notify it of any concerns . Again, as a subscriber to Uptodate, this is a matter that the Trust is likely to be in a position to take up with them.
” 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 a final check of considered treatment and treatment given
Wider context from the report “(1) Ms Kreichgauer left the department without being given antibiotics. The reason for this appears to have been that no-one did a final check on what treatment was considered and whether this had been given to her .
” Open source report
9 Jan 2019 Marian Hoskins · Prevention of Future Deaths report City of London
View report summary
Concerns raised 2 Insufficient outpatient access for informed-consent advice and discussion View source Absence of a system ensuring informed consent before procedure admission View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Marian Hoskins · 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
Marian Hoskins underwent pressure wire testing after a myocardial infarction and coronary stenting, during which an artery was dissected and she subsequently developed a ventricular septal defect. Attempts to repair the defect were unsuccessful or incomplete, and she died from multi-organ failure on 11 January 2017. The principal concern was insufficient discussion of alternative investigations and the absence of a clear system to ensure informed consent was obtained before admission for the procedure.
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 Insufficient outpatient access for informed-consent advice and discussion
Wider context from the report “From the evidence I heard it was apparent that the insufficient discussion with Mrs Hoskins about the investigatory options resulted, in large part at least, from the absence of a clear system and process designed to ensure that full and informed consent is obtained. In particular, the advice and decision making about the pressure wire testing was made (in principle at least) at about the time of her initial percutaneous stenting in October 2016 and without sufficient subsequent out-patient access to advice and discussion .
Prior to the conclusion of the Inquest I received a statement dated 21 November 2018 from ████████, Director of Quality and Safety. ████████ stated that the Trust has started a “major quality improvement project” to improve the process of gaining informed consent and he set out details of steps which have already been taken and those planned. In paragraph 10 of the statement it is noted that informed consent is a process that is undertaken over time and that the Trust’s current process does not include informed consent being obtained prior to the patient being admitted for a specific procedure. I am concerned that the insufficiency of the process in the Deceased’s case resulted largely from the absence /insufficiency of outpatient contact to enable full communication from the clinicians to the patient and family and vice versa, and that this situation persists .
Although ████████ statement indicates that the Trust “will work towards” informed consent being undertaken as an outpatient, the current absence of a system to facilitate informed consent being taken and to ensure it is obtained prior to the patient’s admission for the procedure in question, is of concern in relation to the prevention of future deaths.
” 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 Absence of a system ensuring informed consent before procedure admission
Wider context from the report “From the evidence I heard it was apparent that the insufficient discussion with Mrs Hoskins about the investigatory options resulted, in large part at least, from the absence of a clear system and process designed to ensure that full and informed consent is obtained . In particular, the advice and decision making about the pressure wire testing was made (in principle at least) at about the time of her initial percutaneous stenting in October 2016 and without sufficient subsequent out-patient access to advice and discussion.
Prior to the conclusion of the Inquest I received a statement dated 21 November 2018 from ████████, Director of Quality and Safety. ████████ stated that the Trust has started a “major quality improvement project” to improve the process of gaining informed consent and he set out details of steps which have already been taken and those planned. In paragraph 10 of the statement it is noted that informed consent is a process that is undertaken over time and that the Trust’s current process does not include informed consent being obtained prior to the patient being admitted for a specific procedure . I am concerned that the insufficiency of the process in the Deceased’s case resulted largely from the absence /insufficiency of outpatient contact to enable full communication from the clinicians to the patient and family and vice versa, and that this situation persists.
Although ████████ statement indicates that the Trust “will work towards” informed consent being undertaken as an outpatient, the current absence of a system to facilitate informed consent being taken and to ensure it is obtained prior to the patient’s admission for the procedure in question , is of concern in relation to the prevention of future deaths.
” 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 Consult on the draft informed-consent policy before submitting it for Trust Policies Committee approval.
Verbatim wording from the response “The outcome of this group has been a proposed new Trust policy ‘Informed Consent and Supported Decision Making for Elective Surgical Procedures’. The draft policy is currently out for consultation and we anticipate this will be taken for approval at the Trust Policies Committee within the next 2-3 months.” Source location 2019-0005-Response-by-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 and rigorously implement the revised consent process, including extended outpatient clinic times, consent documentation and revised job plans.
Verbatim wording from the response “We have already discussed the implications of proposed changes to the consent policy at St Bartholomew’s Hospital (extended outpatient clinic times, consent documentation, revised Job Plans etc.). We realise how profound a change the shift in Consent process and policy will be, and are determined to introduce at pace and ensure its rigorous implementation.” Source location 2019-0005-Response-by-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 new Trust policy governing informed consent and supported decision-making for elective surgical procedures.
Verbatim wording from the response “From a Trust perspective work on this matter has been led by the Surgery Network board who established a task and finish group to review consent processes and pathways for elective procedures across the Trust.” Source location 2019-0005-Response-by-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 Submit the informed-consent policy for Trust Policies Committee approval within the anticipated two-to-three-month period.
Verbatim wording from the response “The outcome of this group has been a proposed new Trust policy ‘Informed Consent and Supported Decision Making for Elective Surgical Procedures’. The draft policy is currently out for consultation and we anticipate this will be taken for approval at the Trust Policies Committee within the next 2-3 months.” Source location 2019-0005-Response-by-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 consent-process performance through the Trust’s internal audit, quality and safety meetings, hospital boards and surgical governance structures after policy approval.
Verbatim wording from the response “Following approval of this policy there will be on-going audit of performance, via the trust internal audit schedule, Quality and Safety meetings, hospital boards and via the surgical networks and the surgery board. Training and resource will be given where there are areas for improvement” Source location 2019-0005-Response-by-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 Review Trust consent processes and pathways for elective procedures through a task and finish group.
Verbatim wording from the response “From a Trust perspective work on this matter has been led by the Surgery Network board who established a task and finish group to review consent processes and pathways for elective procedures across the Trust.” Source location 2019-0005-Response-by-Barts-Health-NHS-Trust
Open published response
16 Nov 2018 Dawn Patricia GILL · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 7 Delays in alerting hospital security when an inpatient is missing View source Failure to retain and make available drug charts View source Lack of clarity in the missing-person policy View source Failure to record communications about contacting security for missing patients View source Failure to communicate suspected illicit drug use and associated ward-leaving risk to nursing staff View source Failure to conduct effective searches for missing patients on the ward View source Lack of nursing care planning for patients at increased risk from illicit drug use 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
Dawn Patricia GILL · 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
Dawn Patricia Gill, a long-term drug user, died from a methadone overdose after taking illicit drugs while in the Royal London Hospital alongside prescribed medication. Concerns included the absence of a nursing care plan addressing her drug use, the loss of her drug chart, failures to detect her in her room during searches, and confusion about when to alert hospital security after she was thought to be missing.
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 Delays in alerting hospital security when an inpatient is missing
Wider context from the report “4. Ms Gill was thought to have left the ward for a cigarette some time before 12.30am, though she was not actually seen leaving. She was wearing her night things. When her absence was discovered, hospital security personnel were not alerted . They could have viewed the CCTV. If they had done so, they would have realised that she had never left the ward. Hopefully, this would have prompted a redoubling of the search effort of the ward.
There was confusion about the circumstances when the missing person policy should be followed. I was told that the policy is not clear. The responsible nurse said it was in the back of her mind to contact security and she did not know why she had not. The sister in charge said that she would not contact security for the first two hours . The director of nursing said the contact should be immediate . The clinical site manager and the responsible nurse disagreed about the nature of the conversation between them regarding contacting security. Neither of them had made a note.
There seemed to be a lack of clarity.
” 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 retain and make available drug charts
Wider context from the report “2. Ms Gill was prescribed methadone in hospital and died of a methadone overdose, but her drug chart was not available at inquest and appears to have been lost .
If the drug chart was lost during her life, then that has implications for her care . If it was lost after her death, then that would not have affected care but, how ever innocent the true explanation, it leaves the trust open to an accusation of trying to cover up evidence.
When ever it was lost, its absence is very disappointing. The Barts legal representative at inquest was unaware until I asked to see it on the day that it was missing. He had taken on the file from a colleague a week earlier. He noted that my coroner’s officer had not provided the trust with the report of the post mortem examination until the day before, so he had not known that death was the result of a methadone overdose. This was because the trust had not provided the statements requested. However, Ms Gill had been found in her room on the ward surrounded by drug paraphernalia, so it would have been evident to staff at the outset that drug toxicity was a potential cause of 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 Lack of clarity in the missing-person policy
Wider context from the report “4. Ms Gill was thought to have left the ward for a cigarette some time before 12.30am, though she was not actually seen leaving. She was wearing her night things. When her absence was discovered, hospital security personnel were not alerted. They could have viewed the CCTV. If they had done so, they would have realised that she had never left the ward. Hopefully, this would have prompted a redoubling of the search effort of the ward.
There was confusion about the circumstances when the missing person policy should be followed . I was told that the policy is not clear . The responsible nurse said it was in the back of her mind to contact security and she did not know why she had not. The sister in charge said that she would not contact security for the first two hours. The director of nursing said the contact should be immediate. The clinical site manager and the responsible nurse disagreed about the nature of the conversation between them regarding contacting security. Neither of them had made a note.
There seemed to be a lack of clarity .
” 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 communications about contacting security for missing patients
Wider context from the report “4. Ms Gill was thought to have left the ward for a cigarette some time before 12.30am, though she was not actually seen leaving. She was wearing her night things. When her absence was discovered, hospital security personnel were not alerted. They could have viewed the CCTV. If they had done so, they would have realised that she had never left the ward. Hopefully, this would have prompted a redoubling of the search effort of the ward.
There was confusion about the circumstances when the missing person policy should be followed. I was told that the policy is not clear. The responsible nurse said it was in the back of her mind to contact security and she did not know why she had not. The sister in charge said that she would not contact security for the first two hours. The director of nursing said the contact should be immediate. The clinical site manager and the responsible nurse disagreed about the nature of the conversation between them regarding contacting security. Neither of them had made a note.
There seemed to be a lack of clarity.
” 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 suspected illicit drug use and associated ward-leaving risk to nursing staff
Wider context from the report “1. Ms Gill was a long term drug user and, based on her history, was likely to take illicit drugs whether she was in or out of hospital. However, while she was in hospital, no nursing care plan was made to take this into account, for example by acknowledging the higher risk that it brought. One nursing sister was not even aware that staff suspected Ms Gill of going off the ward to take drugs .
” 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 conduct effective searches for missing patients on the ward
Wider context from the report “3. Ms Gill’s room was described as having been searched on numerous occasions overnight, by more than one person, the first time approximately half an hour after she had last been seen, yet her presence under clothing on the floor was not detected until 10am the following day .
I heard nursing evidence that Ms Gill could not possibly have been in her room at the time of searching, but with the benefit of the CCTV it is now evident that she was.
” 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 nursing care planning for patients at increased risk from illicit drug use
Wider context from the report “1. Ms Gill was a long term drug user and, based on her history, was likely to take illicit drugs whether she was in or out of hospital. However, while she was in hospital, no nursing care plan was made to take this into account, for example by acknowledging the higher risk that it brought . One nursing sister was not even aware that staff suspected Ms Gill of going off the ward to take drugs.
” 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 Remind nursing teams to document suspected illicit drug use in care plans and include it in nursing handovers.
Verbatim wording from the response “During her stay in hospital the wider nursing team and medical staff were aware of the suspicion of Ms Gill taking illicit drugs. She had been spoken to by the consultant and charge nurse and the senior nurse to advise this was not acceptable. However the nursing care plan could and should have been more explicit about this, and if it had been nursing staff would have been more aware of her behaviour and the attendant risks. All nursing teams in the hospital are being reminded of the importance of documenting the use of suspected use of illicit drugs in care plans, and of ensuring this information is part of the nursing handover.” Source location 2018-0354-Response-by-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 Remind nursing staff, using an anonymised case vignette, to keep patient rooms tidy and organised for effective visual inspection.
Verbatim wording from the response “The fundamental problem was that the side room occupied by Ms Gill was crowded and too full of her own possessions, making it difficult for nursing staff to do their job. While the intention was well meaning, the tolerance of Ms Gill’s behaviour with respect to this matter was not in her best interests. All nursing staff have been reminded, through an anonymised vignette of this case, of the need to ensure rooms are kept tidy and organised.
Clearly the checks of the room made by nursing staff during the night in question were not adequate in that they did not detect Ms Gill’s presence. The staff involved did not suspect Ms” Source location 2018-0354-Response-by-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 Provide feedback to staff involved about the danger of assuming a patient is not in their room during searches.
Verbatim wording from the response “Ms Gill’s room was described as having been searched on numerous occasions overnight, by more than one person, the first time approximately half an hour after she had last been seen, yet her presence under clothing on the floor was not detected until 10am the following day.” Source location 2018-0354-Response-by-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 Move to electronic prescribing to eliminate paper drug charts and reduce the risk of charts being lost.
Verbatim wording from the response “The Trust agrees that the inability to locate the drug chart after her death and in preparation for the inquest was a serious failure, and apologises for this. We have since examined the controlled drugs register, which has confirmed that the prescribed doses of methadone in this case had been administered. The Trust accepts that the circumstances of this death made it even more important than usual that the prescribing chart was available after her death, and apologises for this failure.
The Trust is moving in 2019-20 to electronic prescribing. This will eliminate the need for paper based drug charts, and the attendant risk of them being mislaid or lost.” Source location 2018-0354-Response-by-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 Remind nursing teams about the risks of assuming that an absent patient is not on Trust premises.
Verbatim wording from the response “Ms Gill had been judged by the clinical team to have capacity to decide for herself whether she should leave the hospital or not under her own volition. The Barts Health Missing Person / Absconding Patient Policy is clear that this would not classify her absence as a “missing patient” but as a “self-absenting patient”. By this definition she was thought to have been a patient who had capacity, was not subject to legal detention, and who had left the hospital through her own choice, without clinical approval, with the intention of returning. In such circumstances the Trust policy states the Security team should not be called. However the policy recommends that if there is concern that the person may be missing “on Trust premises” then the Security team should be called. The problem here was that the staff did not suspect Ms Gill was on Trust premises, and they should have considered this.” Source location 2018-0354-Response-by-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 Trust lacks the legal powers to prevent patients with capacity from leaving the ward voluntarily.
Verbatim wording from the response “We were aware of her drug habit but we did not see her before her death so would have not have had chance to make any diagnosis or therefore suspected a drug overdose going forward all such patients we will suspect a potential for taking non prescribed drugs and treat accordingly but do not have the powers to stop such patients leaving the ward of their own free will.” Source location 2018-0354-Response-by-Barts-Health-NHS-Trust
Open published response
27 Jun 2018 Angela Sandra Ivina West · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Lack of fluid balance chart availability View source Failure to ensure appropriate staffing arrangements for high-risk postoperative care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Angela Sandra Ivina West · 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
Angela Sandra Ivina West had end stage kidney disease and underwent gall bladder removal surgery on 6 July 2017. She deteriorated over the following days, with tachycardia, acidosis, hyperkalaemia and hypovolemia, and died after suffering a cardiac arrest on 9 July 2017. Concerns included weekend staffing arrangements, her care on a general surgical ward, and the absence of fluid balance charts in relation to dehydration.
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 fluid balance chart availability
Wider context from the report “(3) The investigation highlighted issues relating to Ms West becoming dehydrated. Neither myself nor the clinical investigators were able to locate any fluid balance charts for Ms West.
” 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 appropriate staffing arrangements for high-risk postoperative care
Wider context from the report “(1) Ms West was identified as being at increased risk of surgical complication given her underlying kidney disease. Ms West’s surgery was listed for a Thursday. The effect of this was that much of her care in the period following her deterioration was dealt with under weekend staffing arrangements.
” 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 surgical department doctor numbers and maintain a broader mix of skills across shifts.
Verbatim wording from the response “• The numbers of overall doctors in the surgery department have increased and there is a good mixture of skills sets throughout shifts.” Source location 2018-0212-Response-by-Barts-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 Enhance out-of-hours surgical cover to provide daily review of acute inpatients seven days a week.
Verbatim wording from the response “The following has also been implemented to strengthen this aspect:” Source location 2018-0212-Response-by-Barts-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 General surgical wards, skilled staff, and daily renal-team availability are considered sufficient for managing high-risk renal patients.
Verbatim wording from the response “All our surgical wards expect to look after high risk patients and it’s not unusual to have renal patients such as Ms West on our wards as we have a large cohort of renal patients at the RLH as we are a large renal unit.” Source location 2018-0212-Response-by-Barts-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 Seven-day operational coverage and prepared weekend staff are considered sufficient for high-risk surgery and postoperative care.
Verbatim wording from the response “The Royal London Hospital is fully operational over seven days and 24 hours; high risk surgery can be performed at any time including weekends. Elective high risk surgery has to be performed every day during the working week and weekend staff are fully prepared and set up for post-operative care of high risk surgeries. We recognise that these high standards need to be maintained for all patients and on all our acute surgery wards.” Source location 2018-0212-Response-by-Barts-NHS-Trust
Open published response
6 Jun 2018 William George BARTRAM · Prevention of Future Deaths report London (East)
View report summary
Concerns raised 3 Lack of clear discharge advice to parents about a healthy urine stream in babies View source Lack of a clear process for repeat blood samples in babies and subsequent checking and actioning of results View source Failure of capillary blood gas printouts to highlight abnormal results to clinical staff 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
William George BARTRAM · 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
William Bartram was born with a chordee and hydrocele and was reported to have an inadequate urine stream from shortly after birth. Raised creatinine results and concerns about his urine output were not acted upon, and he died from septic shock on 12 March 2017 after deteriorating in hospital. The principal concerns were unclear processes for repeat blood samples, failure to highlight or act on abnormal results, and inadequate advice to his parents about what constituted a healthy urine stream.
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 clear discharge advice to parents about a healthy urine stream in babies
Wider context from the report “(3) Mr and ████████ did not receive clear advice as to what to look out for, in terms of a healthy urine stream. Advice to parents on the discharge of babies from hospital, would be helpful. Mr and ████████ accepted reassurance from staff, as they were unclear as to what was “normal”.
” 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 clear process for repeat blood samples in babies and subsequent checking and actioning of results
Wider context from the report “(1) The Trust’s investigation report noted that on the 2 March 2017, the parents should not have been advised to attend outpatients for repeat bloods. They should have been advised to return to the emergency department. The A&E registrar who gave evidence during the course of the Inquest, confirmed that staff are not advised to ensure that babies return to the emergency department for repeat bloods. The process for repeat samples is not clear. A clear process for the taking of repeat blood samples for babies would be helpful. A process which would maximise the chances of the results being checked and actioned would be most desirable.
” 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 capillary blood gas printouts to highlight abnormal results to clinical staff
Wider context from the report “(2) A grossly raised creatinine was found on a capillary blood gas sample taken in A&E on 2 March 2017. It was not noted by the clinical staff. It does not appear that the print out from the machine highlighted the result in any way. If abnormal results could be highlighted to clinical staff, this may reduce the risk of abnormal readings being missed.
” Open source report
5 Mar 2018 Mike Fell · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Unavailability of clamps to close unused trauma lines View source Failure to record checks that unused taps are closed to air View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mike Fell · 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
Mike Fell underwent elective abdominal aortic aneurysm repair and later suffered cardiac arrest after a trauma-line 3-way tap was found to be open to air. He sustained a cerebral air embolism and intracerebral bleed, and died in hospital in the early hours of 27 October 2017. Concerns included the absence of recorded checks that unused taps were closed to air and the lack of a clamp on the trauma lines.
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 clamps to close unused trauma lines
Wider context from the report “(2) The trauma lines used at the Royal London Hospital did not come with a clamp which enabled a line that was not in use to be closed
” 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 checks that unused taps are closed to air
Wider context from the report “(1) Whilst it is a matter of routine care to check that unused taps are “closed to air”, it is not recorded in Mr Fell’s notes that the taps had been checked and were closed . It is unclear how or when the 3-way tap on the trauma line became “open to air”
” 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 Discuss with the current supplier changing trauma-line design to allow a clamp to be fitted.
Verbatim wording from the response “These lines have been in use in the Trust for many years and the manufacturer of the line do not supply them with clamps. Currently the anaesthetic department are looking at other companies but it would appear none are made with clamps. We are discussing with our current supplier a change in design to allow a clamp to be fitted; they are interested in working with us as they see this as a problem nationally which has not been raised before in relation to this complication.” Source location 2018-0100-Response-by-Barts-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 Rewrite the policy to prohibit three-way taps on central lines and require self-sealing injection ports.
Verbatim wording from the response “Although we regard this as routine care we have never recorded this in the notes. It is impossible to find out why this particular three way tap was left open; commonly the tap would be open to this port during injection of a drug or connection to an infusion. The tap should be closed before either the syringe is removed from the port or the infusion is removed. Less commonly the three way tap could be ‘opened’ to air by accident during movement of the patient. As a result of this incident we have re-written our policy on the use of central lines and three way taps which states that three way taps should not be used on central lines but self-sealing injection ports should be used. These are available and are in use across the trust. I enclose our up-to-date policy and a Trust wide safety notice to raise awareness of this complication and the new policy.” Source location 2018-0100-Response-by-Barts-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use self-sealing injection ports on central lines across the Trust.
Verbatim wording from the response “Although we regard this as routine care we have never recorded this in the notes. It is impossible to find out why this particular three way tap was left open; commonly the tap would be open to this port during injection of a drug or connection to an infusion. The tap should be closed before either the syringe is removed from the port or the infusion is removed. Less commonly the three way tap could be ‘opened’ to air by accident during movement of the patient. As a result of this incident we have re-written our policy on the use of central lines and three way taps which states that three way taps should not be used on central lines but self-sealing injection ports should be used. These are available and are in use across the trust. I enclose our up-to-date policy and a Trust wide safety notice to raise awareness of this complication and the new policy.” Source location 2018-0100-Response-by-Barts-NHS-Trust
Open published response
22 Jan 2018 Caliel Arlington SMITH-KWAMI · Prevention of Future Deaths report London (East)
View report summary
Concerns raised 6 Failure of the laboratory to notify clinicians when the analyser is not functioning View source Failure to put contingency arrangements in place for analyser failure View source Lack of confirmed availability of bedside ketone testing View source Failure to assign responsibility for chasing test results before discharge View source Lack of electronic record alerts to clinical staff when results are ready View source Failure to chase outstanding test results before discharge 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
Caliel Arlington SMITH-KWAMI · 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
Caliel Arlington Smith-Kwami suffered a profound hypoglycaemic episode around 28 hours after birth and later died on 17 August 2016 from persistent neonatal hyperinsulinaemic hypoglycaemia. He was discharged before key test results were obtained, and concerns included failures to notify clinicians that results were delayed or available, unclear responsibility for chasing results, and a missed opportunity to involve community midwives.
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 the laboratory to notify clinicians when the analyser is not functioning
Wider context from the report “(1) The insulin results were delayed, due to a fault with the analyser. Clinicians were not notified by the lab, that the analyser was not functioning. No alert was sent out. Contingency plans could have been put in place, to ensure that alternative arrangements were made for the test to be analysed before Caliel was discharged from hospital. The independent expert was critical of the lab’s failure to notify clinicians.
” 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 put contingency arrangements in place for analyser failure
Wider context from the report “(1) The insulin results were delayed, due to a fault with the analyser. Clinicians were not notified by the lab, that the analyser was not functioning. No alert was sent out. Contingency plans could have been put in place, to ensure that alternative arrangements were made for the test to be analysed before Caliel was discharged from hospital. The independent expert was critical of the lab’s failure to notify clinicians.
” 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 confirmed availability of bedside ketone testing
Wider context from the report “(4) The independent expert stated that in the absence of the insulin and amino acid profile results, a ketone test might have assisted with the diagnosis. He stated that ketone tests can be obtained at the bedside and that this has recently been introduced within this Trust. No witness at the inquest was able to confirm whether the bedside ketone test was available within Barts Health NHS Trust.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assign responsibility for chasing test results before discharge
Wider context from the report “(2)Test results do not appear to have been chased up before Caliel’s discharge from hospital. It was unclear from the evidence who had the responsibility for chasing up test results prior to discharge.
” 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 electronic record alerts to clinical staff when results are ready
Wider context from the report “(3)The results of the amino acid profile, which raised the possibility of hyperinsulinism were sent through to the electronic record system on the 9 August 2016. It does not appear that any clinician was aware of this result prior to Caliel’s death. The Consultant in Charge of Caliel’s care stated there is no system in place with the electronic record system for highlighting to clinical staff that results are ready. He stated that when paper records were in place, clinicians would result the paper result, but this notification has now been lost.
” 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 chase outstanding test results before discharge
Wider context from the report “(2)Test results do not appear to have been chased up before Caliel’s discharge from hospital. It was unclear from the evidence who had the responsibility for chasing up test results prior to discharge.
” Open source report
28 Nov 2017 Mr Harold Chapman · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Uncertainty in Holter interpretations and identification of NSVTs on traces View source Failure to view, acknowledge and respond to direct-access patient communications View source Lack of checks to ensure review of requested investigations and appropriate action in line with guidelines View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Harold Chapman · 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 Harold Chapman, who had hypertrophic cardiomyopathy, died on 14 June 2016 after developing a significant cardiac arrhythmia. The inquest found that non-sustained ventricular tachycardia identified in 2015 was not reviewed promptly, delaying consideration of an implantable cardioverter defibrillator. A further concern was that patient emails sent to consultants were often not viewed or acted upon, with no response provided.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Uncertainty in Holter interpretations and identification of NSVTs on traces
Wider context from the report “(3) There was also a concern in respect of the holter interpretations and the presence or otherwise of NSVTs on the traces. Barts NHS Trust have instigated a new introduction and training regime for its specialist clinical fellows in the interpretation of holter readings.
” 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 view, acknowledge and respond to direct-access patient communications
Wider context from the report “During the course of the inquest, the evidence revealed during his dealings with the Barts NHS Trust and, more specifically the lead consultants, emails were passed by Mr Chapman to the consultants. It became clear during the inquest that those emails were often not viewed and/or acted upon and as a result no response was received by the patient .
It is fully appreciated that consultants are busy with their clinical responsibilities covering wards, clinics and on-calls.
However, if contact details are provided for ‘direct access’ to individual doctors/consultants, it seems obligatory that those should be viewed, acknowledged and patients responded to .
Patient contact with medical professionals, not just hospital related, is an important part of modern medical practice.
Whilst this is a huge task, it would seem possible to come up with either National or local guidelines in respect of the use of all forms of communication between patients and their clinician (covering phone and emails).
” 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 checks to ensure review of requested investigations and appropriate action in line with guidelines
Wider context from the report “(1) the consultant responsible for Mr Chapman’s care in August and November 2015 was based, at the time, at Barts NHS Trust and is now employed by the Brompton. The consultant was responsible for reviewing the investigations that he (and other members of his team in their absence) had requested.
(2) There appeared to be no check mechanisms in place to ensure that this was done and appropriate action taken in line with the Guidelines..
” 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 Draw up Trust-wide guidance on clinicians’ responsibilities for email communication with patients.
Verbatim wording from the response “More widely, clear guidance is needed for all clinicians on their responsibilities regarding email communication with patients. Trust wide guidelines are being drawn up, working to the following principles:” Source location 2017-0377-Response-by-Barts-Health-NHS-Trust
Open published response
31 Oct 2017 William Henry BERGMAN · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 7 Failure to obtain medical review after head injury View source Failure to obtain detailed symptom information after head injury View source Failure to revise management when new signs emerge after head injury View source Failure to obtain and repeat immediate general observations after head injury View source Delays in completing incident reports View source Failure to consider the potential for serious consequences from head injury in vulnerable older people View source Failure to obtain and repeat immediate neurological observations after head injury 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
William Henry BERGMAN · 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
William Henry Bergman, who had vascular dementia, was admitted to hospital with pneumonia and died after sustaining a forehead impact while being changed on 19 December 2016. He was later found to have a subdural haematoma and massive intracranial bleed. The principal concern was that the staff nurse treated the injury as minor without requesting immediate observations or medical review, and did not change the management plan when a bruise and lump were later noted.
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 obtain medical review after head injury
Wider context from the report “The staff nurse who was called to see Mr Bergman after the accident, quickly formed the opinion that he was fine.
Although the medical records were not available for consideration because Barts Health has been unable to locate them, she said that she would not go into detail such as whether he felt sick.
She did not ask for immediate general observations, then to be repeated. She did not ask for immediate neurological observations, then to be repeated. She did not ask for a medical review.
She said very candidly that she did not consider the possibility of a minor head injury in an elderly person with vascular dementia and liver cirrhosis having the potential for a major consequence.
When she noted a bruise (which a family member attending Mr Bergman that day described as being accompanied by a lump) some hours later, she did not change her management plan.
She completed a Datix report only the following day, after Mr Bergman’s death.
The staff nurse said in court how sorry she was that she had not acted differently, and described her contact with Mr Bergman as career changing.
The reason I write to you now is because if one staff nurse responded in this way to a head injury, immediately assuming that it was minor and therefore with minor consequences, then others may behave in the same way.
” 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 obtain detailed symptom information after head injury
Wider context from the report “The staff nurse who was called to see Mr Bergman after the accident, quickly formed the opinion that he was fine.
Although the medical records were not available for consideration because Barts Health has been unable to locate them, she said that she would not go into detail such as whether he felt sick .
She did not ask for immediate general observations, then to be repeated. She did not ask for immediate neurological observations, then to be repeated. She did not ask for a medical review.
She said very candidly that she did not consider the possibility of a minor head injury in an elderly person with vascular dementia and liver cirrhosis having the potential for a major consequence.
When she noted a bruise (which a family member attending Mr Bergman that day described as being accompanied by a lump) some hours later, she did not change her management plan.
She completed a Datix report only the following day, after Mr Bergman’s death.
The staff nurse said in court how sorry she was that she had not acted differently, and described her contact with Mr Bergman as career changing.
The reason I write to you now is because if one staff nurse responded in this way to a head injury, immediately assuming that it was minor and therefore with minor consequences, then others may behave in the same way.
” 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 revise management when new signs emerge after head injury
Wider context from the report “The staff nurse who was called to see Mr Bergman after the accident, quickly formed the opinion that he was fine.
Although the medical records were not available for consideration because Barts Health has been unable to locate them, she said that she would not go into detail such as whether he felt sick.
She did not ask for immediate general observations, then to be repeated. She did not ask for immediate neurological observations, then to be repeated. She did not ask for a medical review.
She said very candidly that she did not consider the possibility of a minor head injury in an elderly person with vascular dementia and liver cirrhosis having the potential for a major consequence.
When she noted a bruise (which a family member attending Mr Bergman that day described as being accompanied by a lump) some hours later, she did not change her management plan.
She completed a Datix report only the following day, after Mr Bergman’s death.
The staff nurse said in court how sorry she was that she had not acted differently, and described her contact with Mr Bergman as career changing.
The reason I write to you now is because if one staff nurse responded in this way to a head injury, immediately assuming that it was minor and therefore with minor consequences, then others may behave in the same way.
” 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 obtain and repeat immediate general observations after head injury
Wider context from the report “The staff nurse who was called to see Mr Bergman after the accident, quickly formed the opinion that he was fine.
Although the medical records were not available for consideration because Barts Health has been unable to locate them, she said that she would not go into detail such as whether he felt sick.
She did not ask for immediate general observations, then to be repeated. She did not ask for immediate neurological observations, then to be repeated. She did not ask for a medical review.
She said very candidly that she did not consider the possibility of a minor head injury in an elderly person with vascular dementia and liver cirrhosis having the potential for a major consequence.
When she noted a bruise (which a family member attending Mr Bergman that day described as being accompanied by a lump) some hours later, she did not change her management plan.
She completed a Datix report only the following day, after Mr Bergman’s death.
The staff nurse said in court how sorry she was that she had not acted differently, and described her contact with Mr Bergman as career changing.
The reason I write to you now is because if one staff nurse responded in this way to a head injury, immediately assuming that it was minor and therefore with minor consequences, then others may behave in the same way.
” 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 completing incident reports
Wider context from the report “The staff nurse who was called to see Mr Bergman after the accident, quickly formed the opinion that he was fine.
Although the medical records were not available for consideration because Barts Health has been unable to locate them, she said that she would not go into detail such as whether he felt sick.
She did not ask for immediate general observations, then to be repeated. She did not ask for immediate neurological observations, then to be repeated. She did not ask for a medical review.
She said very candidly that she did not consider the possibility of a minor head injury in an elderly person with vascular dementia and liver cirrhosis having the potential for a major consequence.
When she noted a bruise (which a family member attending Mr Bergman that day described as being accompanied by a lump) some hours later, she did not change her management plan.
She completed a Datix report only the following day, after Mr Bergman’s death.
The staff nurse said in court how sorry she was that she had not acted differently, and described her contact with Mr Bergman as career changing.
The reason I write to you now is because if one staff nurse responded in this way to a head injury, immediately assuming that it was minor and therefore with minor consequences, then others may behave in the same way.
” 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 the potential for serious consequences from head injury in vulnerable older people
Wider context from the report “The staff nurse who was called to see Mr Bergman after the accident, quickly formed the opinion that he was fine .
Although the medical records were not available for consideration because Barts Health has been unable to locate them, she said that she would not go into detail such as whether he felt sick.
She did not ask for immediate general observations, then to be repeated. She did not ask for immediate neurological observations, then to be repeated. She did not ask for a medical review.
She said very candidly that she did not consider the possibility of a minor head injury in an elderly person with vascular dementia and liver cirrhosis having the potential for a major consequence .
When she noted a bruise (which a family member attending Mr Bergman that day described as being accompanied by a lump) some hours later, she did not change her management plan.
She completed a Datix report only the following day, after Mr Bergman’s death.
The staff nurse said in court how sorry she was that she had not acted differently, and described her contact with Mr Bergman as career changing.
The reason I write to you now is because if one staff nurse responded in this way to a head injury, immediately assuming that it was minor and therefore with minor consequences , then others may behave in the same way.
” 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 obtain and repeat immediate neurological observations after head injury
Wider context from the report “The staff nurse who was called to see Mr Bergman after the accident, quickly formed the opinion that he was fine.
Although the medical records were not available for consideration because Barts Health has been unable to locate them, she said that she would not go into detail such as whether he felt sick.
She did not ask for immediate general observations, then to be repeated. She did not ask for immediate neurological observations, then to be repeated. She did not ask for a medical review.
She said very candidly that she did not consider the possibility of a minor head injury in an elderly person with vascular dementia and liver cirrhosis having the potential for a major consequence.
When she noted a bruise (which a family member attending Mr Bergman that day described as being accompanied by a lump) some hours later, she did not change her management plan.
She completed a Datix report only the following day, after Mr Bergman’s death.
The staff nurse said in court how sorry she was that she had not acted differently, and described her contact with Mr Bergman as career changing.
The reason I write to you now is because if one staff nurse responded in this way to a head injury, immediately assuming that it was minor and therefore with minor consequences, then others may behave in the same way.
” 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 Introduce a formal trust-wide policy for managing head injury in patients and staff.
Verbatim wording from the response “Certain preventative measures have already been taken. Since October 2017 new post management of head injury guidance and a training package has been rolled out within the Royal London Hospital Older Peoples Service wards with other inpatient areas to follow. The guidance ‘Observation of patients’ with head injury in hospital’ was developed as an interim measure prior to the role out of a more formal and trust wide policy for the management of head injury (patients and staff) next year when this is completed (March 2018).” Source location 2017-0343-Barts-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 Extend the post-head-injury guidance and training rollout to other inpatient areas.
Verbatim wording from the response “Certain preventative measures have already been taken. Since October 2017 new post management of head injury guidance and a training package has been rolled out within the Royal London Hospital Older Peoples Service wards with other inpatient areas to follow. The guidance ‘Observation of patients’ with head injury in hospital’ was developed as an interim measure prior to the role out of a more formal and trust wide policy for the management of head injury (patients and staff) next year when this is completed (March 2018).” Source location 2017-0343-Barts-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 new post-head-injury guidance and training across Royal London Hospital Older Peoples Service wards.
Verbatim wording from the response “Certain preventative measures have already been taken. Since October 2017 new post management of head injury guidance and a training package has been rolled out within the Royal London Hospital Older Peoples Service wards with other inpatient areas to follow. The guidance ‘Observation of patients’ with head injury in hospital’ was developed as an interim measure prior to the role out of a more formal and trust wide policy for the management of head injury (patients and staff) next year when this is completed (March 2018).” Source location 2017-0343-Barts-NHS-Trust
Open published response
20 Apr 2017 Mr Errol Mann · Prevention of Future Deaths report London (East)
View report summary
Concerns raised 2 Gaps in the ICU Clinical Fellow rota View source Lack of administrative support in the ICU 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
Mr Errol Mann · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Errol Mann was admitted to hospital with suspected hyperosmolar hyperglycaemia, sepsis and pulmonary embolism, and later suffered a fatal pulmonary embolism on 7 August 2015. The report identified failures to investigate or exclude pulmonary embolism and to ensure consistent VTE prophylaxis, and raised concerns about inadequate ICU staffing affecting patient 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 Gaps in the ICU Clinical Fellow rota
Wider context from the report “Evidence was given by a Consultant in ITU that the ICU department was extremely short staffed during the week of 3rd – 6th August 2015. The Consultant confirmed that there was no administrative support and there were several gaps in the rota for Clinical Fellows . She confirmed that because of staffing issues, the time of the Consultant on duty was not fully devoted to clinical care. She gave evidence that the lack of staff directly affected the care provided to Mr Mann. She confirmed that the concerns were escalated to the Medical Director at that time but that no additional manpower was provided. When asked whether staffing on ICU was still a problem and whether this still affects patient safety, the Consultant confirmed that staffing issues vary depending upon the time of year. She stated however that “we have never been fully recruited on the clinical fellow front. There are still gaps in the rota ”.
She stated that even as of the 31st March 2017 gaps continue and as long as there are gaps on the rota, patient care is affected.
” 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 administrative support in the ICU
Wider context from the report “Evidence was given by a Consultant in ITU that the ICU department was extremely short staffed during the week of 3rd – 6th August 2015. The Consultant confirmed that there was no administrative support and there were several gaps in the rota for Clinical Fellows. She confirmed that because of staffing issues, the time of the Consultant on duty was not fully devoted to clinical care. She gave evidence that the lack of staff directly affected the care provided to Mr Mann. She confirmed that the concerns were escalated to the Medical Director at that time but that no additional manpower was provided. When asked whether staffing on ICU was still a problem and whether this still affects patient safety, the Consultant confirmed that staffing issues vary depending upon the time of year. She stated however that “we have never been fully recruited on the clinical fellow front. There are still gaps in the rota”.
She stated that even as of the 31st March 2017 gaps continue and as long as there are gaps on the rota, patient care is affected.
” Open source report
6 Feb 2017 Nuala Seddon · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 5 Lack of appropriate monitoring for patients discharged from ITU View source Failure to ensure clinical staff make discharge decisions View source Failure to investigate patient safety events appropriately View source Lack of available telemetry monitoring for patients discharged from ITU View source Lack of documentation of significant discharge decisions 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
Nuala Seddon · 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
Nuala Seddon developed a hypoxic brain injury after a cardiac arrest on 27 November 2014, following her transfer from ITU to ward-based care, and died on 7 April 2016 after developing pneumonia. The report raised concern that a lack of available telemetry could expose patients discharged from ITU to significant risk of unrecognised deterioration.
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 appropriate monitoring for patients discharged from ITU
Wider context from the report “(2) The lack of both telemetry and direct nursing visualisation raises a concern that patients who are discharged from the highest level of clinical care on ITU are then exposed to significant risk of unrecognised deterioration, owing to a lack of appropriate monitoring . This potentially remains the case even though the Heart Hospital has now transferred to be part of Barts NHS Trust, as the hospital at Westmoreland Street still operates as part of UCLH.
” 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 clinical staff make discharge decisions
Wider context from the report “(1) It seems clear that a decision was made to transfer Mrs Seddon from ITU on 27 November 2014. There remains the potential that this decision was made by non-clinical staff. The lack of documentation regarding this significant decision is concerning and leaves open the possibility that future discharges could be based on non-clinical need or inappropriate decision-making which is not subsequently able to be scrutinised because of a lack of documentation.
” 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 patient safety events appropriately
Wider context from the report “(3) The ward nurse who was caring for Mrs Seddon at the point of her arrest was not involved in any debrief or significant event investigation . This raises a concern that there was a lack of appropriate investigation into Mrs Seddon’s arrest . Future deaths could occur if the hospital Trust is not able to identify and address patient safety issues because of this failure to investigate appropriately .
” 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 available telemetry monitoring for patients discharged from ITU
Wider context from the report “(1) I heard evidence from the ward nurse that concerns regarding lack of available telemetry remain a current issue at the Heart Hospital (which is now part of Barts NHS Trust). This raises a concern that patients who are discharged from the highest level of clinical care on ITU are then exposed to significant risk of unrecognised deterioration, owing to a lack of appropriate monitoring .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of documentation of significant discharge decisions
Wider context from the report “(1) It seems clear that a decision was made to transfer Mrs Seddon from ITU on 27 November 2014. There remains the potential that this decision was made by non-clinical staff. The lack of documentation regarding this significant decision is concerning and leaves open the possibility that future discharges could be based on non-clinical need or inappropriate decision-making which is not subsequently able to be scrutinised because of a lack of documentation .
” Open source report
20 Jun 2016 Mr Zawdie Qounseye Bascom · Prevention of Future Deaths report London (East)
View report summary
Concerns raised 4 Failure to audit pain management for patients presenting to A&E in severe pain View source Failure to ensure relief of severe pain before discharge View source Failure to record pain scores at A&E triage View source Failure to systematically reassess pain after analgesia and before discharge View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mr Zawdie Qounseye Bascom · 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 Zawdie Qounseye Bascom developed severe abdominal pain, was assessed and discharged from A&E with a presumed diagnosis of gastritis, and later collapsed and died on 12 May 2014. The post-mortem cause of death was peritonitis due to rupture of an inflamed vermiform appendix. Concerns included inadequate recording and systematic assessment of pain, lack of documented pain relief before discharge, and insufficient attention to persistent severe pain that was unusual for gastritis.
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 audit pain management for patients presenting to A&E in severe pain
Wider context from the report “1) Mr Bascom presented in severe pain to A&E. This was his primary presenting problem. Despite this, there was no recording of his pain score on triage into A&E.
2) Analgesic medication was administered at 03:45 and a pain score recorded at 05:15 of 9/10. The doctor who recorded the pain score at that time could not recall whether he had any regard to the fact that analgesia had been given, when he noted the score of 9/10.
3) Further analgesia in the form of tramadol was given at 05:30. There was no further pain score recorded following this analgesia. No pain score was recorded prior to discharge.
4) On the basis of the evidence heard I found that Mr Bascom’s pain was not relieved prior to discharge. There was no documentation at all to support pain relief and ████████ confirmed that Mr Bascom continued to require support as a result of the pain, when he left the hospital. The independent expert gave evidence that the severe pain reported by Mr Bascom would be unusual in a case of gastritis.
5) It was noted in evidence that the Trust carries out pain audits in compliance with the College of Emergency Medicine. The consultant who gave evidence was unable to comment upon the practice at Newham University Hospital. The updated action plan referred only to regular audits in relation to sickle cell, fractured hip, and pain in children. The updated action plan does not address the circumstances where patients present to A&E in severe pain.
6) No pain score was recorded by any member of the nursing team. There was no evidence of any systematic assessment of pain (for example, response to analgesia).
” 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 relief of severe pain before discharge
Wider context from the report “1) Mr Bascom presented in severe pain to A&E. This was his primary presenting problem. Despite this, there was no recording of his pain score on triage into A&E.
2) Analgesic medication was administered at 03:45 and a pain score recorded at 05:15 of 9/10. The doctor who recorded the pain score at that time could not recall whether he had any regard to the fact that analgesia had been given, when he noted the score of 9/10.
3) Further analgesia in the form of tramadol was given at 05:30. There was no further pain score recorded following this analgesia. No pain score was recorded prior to discharge.
4) On the basis of the evidence heard I found that Mr Bascom’s pain was not relieved prior to discharge. There was no documentation at all to support pain relief and ████████ confirmed that Mr Bascom continued to require support as a result of the pain, when he left the hospital. The independent expert gave evidence that the severe pain reported by Mr Bascom would be unusual in a case of gastritis.
5) It was noted in evidence that the Trust carries out pain audits in compliance with the College of Emergency Medicine. The consultant who gave evidence was unable to comment upon the practice at Newham University Hospital. The updated action plan referred only to regular audits in relation to sickle cell, fractured hip, and pain in children. The updated action plan does not address the circumstances where patients present to A&E in severe pain.
6) No pain score was recorded by any member of the nursing team. There was no evidence of any systematic assessment of pain (for example, response to analgesia).
” 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 pain scores at A&E triage
Wider context from the report “1) Mr Bascom presented in severe pain to A&E. This was his primary presenting problem. Despite this, there was no recording of his pain score on triage into A&E.
2) Analgesic medication was administered at 03:45 and a pain score recorded at 05:15 of 9/10. The doctor who recorded the pain score at that time could not recall whether he had any regard to the fact that analgesia had been given, when he noted the score of 9/10.
3) Further analgesia in the form of tramadol was given at 05:30. There was no further pain score recorded following this analgesia. No pain score was recorded prior to discharge.
4) On the basis of the evidence heard I found that Mr Bascom’s pain was not relieved prior to discharge. There was no documentation at all to support pain relief and ████████ confirmed that Mr Bascom continued to require support as a result of the pain, when he left the hospital. The independent expert gave evidence that the severe pain reported by Mr Bascom would be unusual in a case of gastritis.
5) It was noted in evidence that the Trust carries out pain audits in compliance with the College of Emergency Medicine. The consultant who gave evidence was unable to comment upon the practice at Newham University Hospital. The updated action plan referred only to regular audits in relation to sickle cell, fractured hip, and pain in children. The updated action plan does not address the circumstances where patients present to A&E in severe pain.
6) No pain score was recorded by any member of the nursing team. There was no evidence of any systematic assessment of pain (for example, response to analgesia).
” 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 systematically reassess pain after analgesia and before discharge
Wider context from the report “1) Mr Bascom presented in severe pain to A&E. This was his primary presenting problem. Despite this, there was no recording of his pain score on triage into A&E.
2) Analgesic medication was administered at 03:45 and a pain score recorded at 05:15 of 9/10. The doctor who recorded the pain score at that time could not recall whether he had any regard to the fact that analgesia had been given, when he noted the score of 9/10.
3) Further analgesia in the form of tramadol was given at 05:30. There was no further pain score recorded following this analgesia. No pain score was recorded prior to discharge.
4) On the basis of the evidence heard I found that Mr Bascom’s pain was not relieved prior to discharge. There was no documentation at all to support pain relief and ████████ confirmed that Mr Bascom continued to require support as a result of the pain, when he left the hospital. The independent expert gave evidence that the severe pain reported by Mr Bascom would be unusual in a case of gastritis.
5) It was noted in evidence that the Trust carries out pain audits in compliance with the College of Emergency Medicine. The consultant who gave evidence was unable to comment upon the practice at Newham University Hospital. The updated action plan referred only to regular audits in relation to sickle cell, fractured hip, and pain in children. The updated action plan does not address the circumstances where patients present to A&E in severe pain.
6) No pain score was recorded by any member of the nursing team. There was no evidence of any systematic assessment of pain (for example, response to analgesia).
” Open source report
11 Nov 2015 David Alan White · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Failure to record and act on Heparin-induced confusion View source Lack of supervision arrangements for falls and mobilisation risk View source Failure to review and act on nursing risk records View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David Alan White · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Alan White was admitted to hospital with significant pain from arterial vascular disease and later sustained two unwitnessed falls, the second causing fractures to his right hip and shoulder. He underwent emergency surgery and subsequently remained seriously unwell before dying on 26 June 2015. Concerns included the failure to record or act on reported confusion associated with Heparin, lack of supervision despite identified falls risks, and inadequate review and action on nursing records.
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 record and act on Heparin-induced confusion
Wider context from the report “(1) The effect of Heparin, in causing confusion, was not in the records , and therefore not acted upon .
” 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 supervision arrangements for falls and mobilisation risk
Wider context from the report “(2) Nursing notes documented a risk of falls/mobilisation and action to be taken, but there was no supervision arrangement in place . One to one care had been in contemplation .
” 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 and act on nursing risk records
Wider context from the report “(3) Whilst nursing notes were being kept about the risks, the records were not being reviewed and acted upon .
” 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 Include verbal handover of falls-risk patients’ care plans in nursing handover safety briefings.
Verbatim wording from the response “2. The safety briefing during nursing handover is now to include a verbal handover of the care plans for patients assessed as at risk of falls to alert incoming staff members as to the risk and care plan.” Source location 2015-0437-Response
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 Move Ward 9F multidisciplinary meetings earlier to develop falls-risk action plans and communicate overnight deterioration.
Verbatim wording from the response “3. Multidisciplinary Team meetings on Ward 9F have now been changed to earlier in the day to discuss patients and make effective action plans for patient at risk of falls. This meeting consists of medical/surgical teams, physiotherapy, Occupational Therapists and the Ward Nurse in charge and includes a medical handover to ensure communication of any deterioration overnight that could influence risk of falls, such as increased confusion.” Source location 2015-0437-Response
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 documenting drug allergies and adverse effects and escalate drug-related issues to senior clinical staff.
Verbatim wording from the response “1. The members of staff have been reminded of the importance of adhering to the normal process of ‘documenting allergies and adverse effects’ regardless of how unique the reaction may be as in this case. This issue has also been discussed in the Renal Mortality and Morbidity meeting as a learning point for” Source location 2015-0437-Response
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 practice development team to support ward adherence to documentation, risk-assessment and communication protocols.
Verbatim wording from the response “A practice development team has been recruited to support ward staff in adhering to ward protocols and procedures including documentation, assessment of risks and communication. We also have facilitated training from the ‘Falls Lead’ for the Trust to re-train nurses regarding the fall procedure and management and this took place on 29 June 2015.” Source location 2015-0437-Response
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 escalation of one-to-one supervision requests and enable out-of-hours site-manager contact for patients at risk of falls or confusion.
Verbatim wording from the response “We have reviewed the escalation of our ‘Specials’ requests to Bank Partners so that patients can be appropriately monitored and supervised (one to one) when they are assessed as at risk of falls and/or confused. Site managers can now be contacted out of hours to ensure appropriate management of care.” Source location 2015-0437-Response
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 Falls Lead training to retrain nurses in fall procedures and management.
Verbatim wording from the response “A practice development team has been recruited to support ward staff in adhering to ward protocols and procedures including documentation, assessment of risks and communication. We also have facilitated training from the ‘Falls Lead’ for the Trust to re-train nurses regarding the fall procedure and management and this took place on 29 June 2015.” Source location 2015-0437-Response
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 nursing staff to audit daily nursing and falls-risk documentation, including call-bell access, assessments and care-plan changes.
Verbatim wording from the response “It has been emphasised to all senior nursing staff that daily auditing of all nursing and falls risk documentation must be carried out. This will ensure that call bells are within reach of patients and that all assessments and any changes in care plans are highlighted in the medical records.” Source location 2015-0437-Response
Open published response
19 Feb 2015 John DACK · Prevention of Future Deaths report London Inner (North)
View report summary
Concerns raised 2 Failure to maintain accurate patient addresses in medical notes View source Inappropriate early discharge home following MDT meetings View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John DACK · 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 Dack sustained fractures to both ankles, underwent procedures and was discharged home unable to weight bear without the planned follow-up. He later developed an infected left ankle with osteomyelitis and died on 24 September 2014 after hospital treatment. The report’s principal concern was that an incorrect address in his medical notes prevented follow-up despite notifications from his daughter; it also raised concern about early discharge home after the MDT meeting.
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 maintain accurate patient addresses in medical notes
Wider context from the report “Mr Dack was not called for follow up because his medical notes recorded the wrong address for him , despite the fact that one of his daughters had notified staff of this on two separate occasions . What seems at first blush to be a relatively unimportant administrative matter can therefore have serious consequences. I heard from the surgeon treating Mr Dack that this has happened before with other patients . It seems that this part of the system of administration would benefit from 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 Inappropriate early discharge home following MDT meetings
Wider context from the report “(No witness was able to offer any suggestions for changes to the hospital system that might prevent inappropriate early discharge home following MDT meeting on another occasion .)
” 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 Emphasize to relevant staff the importance of accurately recording and changing patient details.
Verbatim wording from the response “Our investigation has concluded that the ward clerk was told to change Mr Dack’s address by the patient’s nurse. A mistake was made however as she recorded him as being of ‘no fixed abode’. We have asked the ward matron to speak to her staff to remind them of the importance of accurately changing patient details and the consequences of not doing so.” Source location 2015-0151-Response-by-Barts-Health-NHS
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 clerical address error did not cause Mr Dack to be lost to follow-up because he knew about and rearranged his appointment.
Verbatim wording from the response “Your concern was that Mr Dack was not called for follow up because his medical notes recorded the wrong address for him, despite the fact that one of his daughters had notified staff.” Source location 2015-0151-Response-by-Barts-Health-NHS
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations