11 Feb 2015 Rufjan BIBI · Prevention of Future Deaths report Inner North London
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Concerns raised 3 Delays in consultant review for patients with impaired consciousness View source Patients being expected to obtain private nursing support to receive appropriate hospital care View source Failure to provide timely continence and personal care assistance View source
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AI-generated summary
Rufjan BIBI · 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
Rufjan Bibi, who had Parkinson’s disease and a previous subdural haematoma, fell at Mile End Hospital on 1 July 2014 and hit her head. The report raised concerns about inadequate nursing assistance and personal care, a suggestion that the family privately engage a nurse, and a five-hour delay before consultant review after the fall.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in consultant review for patients with impaired consciousness
Wider context from the report “3. Having been found at just before 2pm, Ms Bibi did not receive a consultant review until 7pm , and arrangements were then made for her transfer to the Royal London Hospital.
During the intervening five hours, she had a Glasgow Coma Score of ten , yet no witness was able to explain the delay .
” 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 Patients being expected to obtain private nursing support to receive appropriate hospital care
Wider context from the report “2. Family members were also unhappy that a nurse had told them that, if they wanted closer care for Ms Bibi, then they could engage a nurse privately to come to the hospital to look after her .
If this is seriously being suggested as the way for a patient in an NHS hospital to receive appropriate care, then it is worrying indeed for all patients.
If it is not seriously being suggested, then it seems unkind and unnecessary.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely continence and personal care assistance
Wider context from the report “1. Ms Bibi’s family told me at inquest that when they came to visit Ms Bibi, which they did daily, they often found her in need of changing (she was incontinent), and then had difficulty obtaining prompt nurse assistance .
They even found her with faeces in her hair.
Whilst this did not impact upon the outcome, it made me question the evidence I had been given about frequent nursing contact, in a way that I would not otherwise have done. (And of course, however busy staff are, it is not a situation that any of us would want for our loved ones.)
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement intentional rounding to monitor patients’ needs and safety.
Verbatim wording from the response “Certain actions have already been taken. Intentional rounding has been implemented as have documentation audits as part of the Clinical Friday initiative which involves senior nurses carrying out a ward round every 1st and 3rd Fridays looking at safety and quality issues. Observations of care are also being carried out. This is an independent observation of the activity of a set team or ward area for a period of time which is then followed by a meeting between the observer and individual staff. The observation surveys a variety of things such as interactions between staff, patients and the public, telephone calls, 1:1 care and even practices such as infection prevention. The intention of the meeting afterwards is to allow the individual member of staff to reflect on their practice and on how they were perceived, allowing them to” Source location 2015-0053-Response-by-Barts-Health-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explain the escalation policy to new trainees, including timely assessment, intervention, documentation and senior review.
Verbatim wording from the response “████████ has also met with the new trainees who joined the department on the 01 April 2015. She explained the department’s escalation policy regarding patients on the rehabilitation site or on any of the wards, who become acutely unwell. Timely assessment and intervention with good documentation are essential in ensuring that acute serious problems are treated appropriately. Senior review should always be sought expeditiously so that on-going management can be planned. Any adverse incidents on the ward, whether resulting in harm or not, should always be discussed and documented with patients and/or relatives as appropriate. Plans for on-going care should be specified. The aim of this training to juniors is to prevent delay in care that is likely to result in harm to our patients.” Source location 2015-0053-Response-by-Barts-Health-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train staff to obtain prompt consultant review for acutely unwell patients or potentially dangerous injuries.
Verbatim wording from the response “The delay in obtaining a consultant review is not usual practice and should not have happened. The member of staff involved has been given training about obtaining a consultant review when a patient is acutely unwell or suffers a potentially dangerous injury. The doctor will also reflect on this incident in their portfolio.” Source location 2015-0053-Response-by-Barts-Health-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Carry out independent observations of care followed by reflective feedback with staff.
Verbatim wording from the response “Certain actions have already been taken. Intentional rounding has been implemented as have documentation audits as part of the Clinical Friday initiative which involves senior nurses carrying out a ward round every 1st and 3rd Fridays looking at safety and quality issues. Observations of care are also being carried out. This is an independent observation of the activity of a set team or ward area for a period of time which is then followed by a meeting between the observer and individual staff. The observation surveys a variety of things such as interactions between staff, patients and the public, telephone calls, 1:1 care and even practices such as infection prevention. The intention of the meeting afterwards is to allow the individual member of staff to reflect on their practice and on how they were perceived, allowing them to” Source location 2015-0053-Response-by-Barts-Health-NHS-Trust
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Private one-to-one carers are not usual practice; patients are assessed against criteria and professional judgement determines whether special care is needed.
Verbatim wording from the response “This was also discussed at the Local Resolution Meeting held between Trust staff and Mrs Bibi’s family. Apologies were made; however, as there was communication issues between Trust staff and the family, the Trust did feel that this was very unlikely to have been said. It is not usual practice to have private 1:1 carers and it is not an option at present. This would offer. All patients are assessed on admission and regularly reassessed throughout their stay. Mrs Bibi did not meet the Trusts criteria for 1:1 nursing and the staff caring for her had the time used professional judgement to determine if special care was needed for her outside of the written criteria.” Source location 2015-0053-Response-by-Barts-Health-NHS-Trust
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust stated that medical review and appropriate post-fall checks occurred soon after the fall, contrary to the reported five-hour delay.
Verbatim wording from the response “This also was discussed at the Local Resolution Meeting and an apology made to the family. The consultant in charge, doctor ████████, has spoken to the junior doctor who was assigned to the ward at that time. They remember assessing the patient but did not remember documenting the assessment. The medical review was undertaken very soon after the fall as the Medical Team were on the ward when the fall occurred. Nursing documentation supports that a review and appropriate checks were instigated as per Barts Health Post-Falls procedures.” Source location 2015-0053-Response-by-Barts-Health-NHS-Trust
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust considered it very unlikely that staff told the family to privately engage a one-to-one nurse.
Verbatim wording from the response “This was also discussed at the Local Resolution Meeting held between Trust staff and Mrs Bibi’s family. Apologies were made; however, as there was communication issues between Trust staff and the family, the Trust did feel that this was very unlikely to have been said. It is not usual practice to have private 1:1 carers and it is not an option at present. This would offer. All patients are assessed on admission and regularly reassessed throughout their stay. Mrs Bibi did not meet the Trusts criteria for 1:1 nursing and the staff caring for her had the time used professional judgement to determine if special care was needed for her outside of the written criteria.” Source location 2015-0053-Response-by-Barts-Health-NHS-Trust
Open published response
20 Jan 2015 Mrs Awa Jeng · Prevention of Future Deaths report London (East)
View report summary
Concerns raised 7 Failure to ensure communication of requests for clinically required tests View source Delays in repeating arterial blood gas tests View source Failure to provide medical review View source Failure to provide close monitoring of patients at high risk of acute deterioration View source Failure of handover of responsibilities and tasks between day and night shifts View source Insufficient nursing observations of ward patients View source Failure to repeat blood tests within the required timeframe View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mrs Awa Jeng · 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 Awa Jeng was admitted after a fall that caused a fractured left hip and underwent surgery. She subsequently required dialysis but was not adequately monitored on the ward, and tests were delayed until her potassium was at a life-threatening level. She deteriorated, suffered cardiac arrest during intubation, and could not be resuscitated; the inquest concluded that inadequate monitoring and delayed haemofiltration contributed to her death.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure communication of requests for clinically required tests
Wider context from the report “3. The blood tests were not repeated until the following morning when they had deteriorated to a life threatening level.
4. It was not clear from the evidence why the blood tests were not repeated. The FY2 did write a retrospective note confirming that she had asked the on-call doctor to perform the test. Evidence from the on-call doctor denied that this information was passed on to her.
” 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 repeating arterial blood gas tests
Wider context from the report “2. The ITU consultant gave a clear direction to the FY2 on Tayberry Ward during the afternoon of the 19th December 2013 that the arterial blood gases should be repeated that evening and she should be checked for signs of pulmonary oedema and fluid overload.
” 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 medical review
Wider context from the report “5. Mrs Jeng was also not monitored appropriately on the ward on the evening of 19 December. There was no medical review and insufficient nursing observations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide close monitoring of patients at high risk of acute deterioration
Wider context from the report “1. Mrs Jeng was at high risk of suffering life threatening acute renal failure. Her regular dialysis was due on the 19th December 2013. Bearing in mind the recent trauma and necessary surgery, an acute deterioration in her condition should have been foreseeable. In the circumstances, she required close 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 Failure of handover of responsibilities and tasks between day and night shifts
Wider context from the report “6. I note that the Trust’s internal investigation raised concerns in relation to the handover of responsibilities and tasks between day and night shifts . There is however currently no clear action to address 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 Insufficient nursing observations of ward patients
Wider context from the report “5. Mrs Jeng was also not monitored appropriately on the ward on the evening of 19 December. There was no medical review and insufficient nursing observations .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to repeat blood tests within the required timeframe
Wider context from the report “3. The blood tests were not repeated until the following morning when they had deteriorated to a life threatening level.
4. It was not clear from the evidence why the blood tests were not repeated. The FY2 did write a retrospective note confirming that she had asked the on-call doctor to perform the test. Evidence from the on-call doctor denied that this information was passed on to her.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train nursing staff in recognising deteriorating patients and appropriately escalating concerns.
Verbatim wording from the response “For clarity, the changes described (above) also apply to Tayberry Ward. Mrs Jeng’s death has been discussed at safety briefings on Tayberry Ward. The care and treatment of the deteriorating patient and the appropriate escalation of concerns is also a priority on the ward. Funding has been received for nursing staff to be trained to attain this specific skill set, at London Southbank University.” Source location 2015-0015-Response-by-Barts-Health-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve participation by all on-call teams in refreshed hospital-at-night meetings to review patients flagged as at risk.
Verbatim wording from the response “During Stepping into the Future Programme (a pan-London NHS initiative to ensure that patient experience and safety is optimal) Newham University Hospital has refreshed the hospital at night meeting and work is under way to improve participation by all on-call teams at night to review and discuss patients flagged as at risk at the start of the shift. This includes the introduction of afternoon safety huddles which are open to all staff and disciplines where issues can be raised and resolved.” Source location 2015-0015-Response-by-Barts-Health-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Send written and verbal instructions requiring junior doctors to record out-of-hours review needs on the trauma sheet before ending shifts.
Verbatim wording from the response “Instructions verbally and written have been sent to all junior doctors in orthopaedics and orthogeriatrics regarding their responsibilities to add details of any patient requiring review out of hours to the trauma sheet before finishing their shifts.” Source location 2015-0015-Response-by-Barts-Health-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Pilot Vitalslink wireless vital-sign monitoring with real-time alerts linked to the electronic patient record.
Verbatim wording from the response “Newham University Hospital has been awarded funding to implement a vital signs monitoring process known as Vitalslink which will transmit clinical observations to the Electronic Patient Record (EPR) by Wi-Fi and give real-time feedback to the clinician regarding at risk status and the appropriate action to take. This is currently being piloted at Newham University Hospital with wider roll-out planned once the pilot is approved.” Source location 2015-0015-Response-by-Barts-Health-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement revised NEWS and CREWS early warning scores across Newham University Hospital and the Trust.
Verbatim wording from the response “During the investigation, senior clinical staff involved were contacted and confirmed that the Trust is implementing a revised early warning score National Early Warning Score (NEWS) and Chronic Respiratory Early Warning Score (CREWS) which once implemented is expected to improve compliance with contacting and escalating assistance with deteriorating patients. This is being implemented at Newham University Hospital imminently, as well as across the Trust.” Source location 2015-0015-Response-by-Barts-Health-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add signing and dating requirements to orthopaedic handover sheets and retain them for audit and transparency.
Verbatim wording from the response “There is a formal list and documentation for this meeting, an action plan for each patient and a record is kept and recorded on the sheet. This document forms the basis for the formal face-to-face handover meeting between the day and night medical teams.” Source location 2015-0015-Response-by-Barts-Health-NHS-Trust
Open published response
15 Dec 2014 Andrew James AITKEN · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 5 Failure to safely secure medication brought into hospital View source Failure to obtain relevant previous inpatient mental health records View source Failure to investigate and respond to complaints View source Failure to ensure patients have appropriate clothing and footwear at discharge View source Failure to provide direct referral to community mental health services for patients without a GP View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Andrew James AITKEN · 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
Andrew Aitken was admitted to hospital on 10 June 2014 after taking a drug overdose, was treated and discharged on 16 June. Two months later he was found dead at home from amitriptyline toxicity, without having accessed mental health care in the meantime. Concerns included the handling of the remaining tablets, failure to seek records of a previous psychiatric admission, lack of direct referral to community mental health services despite him having no GP, and his discharge without clothes or shoes.
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 safely secure medication brought into hospital
Wider context from the report “1. When Mr Aitken was admitted to hospital on 10 June 2014, his girlfriend brought in the remainder of the tablets he had taken, hoping to assist those treating him.
████████ told me that a nurse took the tablets from her, of which there were still many remaining, and simply left them on the hospital bedside cabinet next to Mr Aitken .
” 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 relevant previous inpatient mental health records
Wider context from the report “2. Mr Aitken had been admitted to Prestwich Hospital Psychiatric Hospital when he was 16 years old. When he was admitted on 10 June 2014, no consideration was given to asking for any record of that inpatient stay .
That was some 14 years earlier and may not have yielded anything useful but, as Mr Aitken was not registered with a general practitioner, it was the only source of history from healthcare professionals.
” 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 and respond to complaints
Wider context from the report “4. I was told that Mr Aitken was discharged from hospital in gown and socks, with no clothes or shoes.
I understand that East London Trust has now decided to undertake a serious incident review, but I am concerned that ████████ has already written to the Royal London Hospital, has received no response to that letter , and has been told that there is no ongoing investigation into her complaint .
” 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 patients have appropriate clothing and footwear at discharge
Wider context from the report “4. I was told that Mr Aitken was discharged from hospital in gown and socks, with no clothes or shoes .
I understand that East London Trust has now decided to undertake a serious incident review, but I am concerned that ████████ has already written to the Royal London Hospital, has received no response to that letter, and has been told that there is no ongoing investigation into her complaint.
” 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 direct referral to community mental health services for patients without a GP
Wider context from the report “3. The junior psychiatrist discharging Mr Aitken did strongly advise him to register with a GP and then to seek referral to mental health services, but it did not occur to her to refer him direct to the community mental health team, given that he had no GP .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The second and third concerns are being investigated and addressed separately by East London NHS Foundation Trust.
Verbatim wording from the response “Your second and third concerns are being investigated and addressed separately by the East London NHS Foundation Trust.” Source location 2014-0561-Response-by-Barts-Health-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The ward had done everything possible regarding discharge without clothes or shoes, so the safeguarding alert was closed.
Verbatim wording from the response “The investigation involved communicating with ████████ who is the senior sister on ward 11C. She told me that she remembered this man very well. She stated that he was medically fit and the psychiatry team had discharged him; he was willing to go home and so they could not keep him in hospital. He did not have any clothes with him and he told staff that no one could bring him any in. The Trust booked and paid for a taxi to take him home as they did not want him going home on public transport in hospital pyjamas. The ward did receive a complaint in June whereby a safeguarding alert was raised, although it was deemed that the ward had done everything it could at the time and so the safeguarding was closed.” Source location 2014-0561-Response-by-Barts-Health-NHS-Trust
Open published response
17 Oct 2014 Stephen Atherton · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Delays in radiologist-recommended additional investigations when GPs cannot request them View source Lack of a system at the GP practice to ensure successful receipt of important correspondence View source Failure to clinically triage routine orthopaedic referrals View source Lack of appropriate safeguards to prevent patients at risk from leaving before capacity assessment View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Stephen Atherton · 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
Stephen Atherton, aged 27, died on 16 May 2013 from severe head injuries after falling from height after leaving a neurosurgical ward. The report identified concerns about delays and communication in referrals and investigations, and about the absence of safeguards to prevent him leaving the ward despite risks to himself.
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 radiologist-recommended additional investigations when GPs cannot request them
Wider context from the report “(3) Mr Atherton required multiple investigations of increasing complexity, at the recommendation of the reporting radiologists. I heard compelling evidence from Mr Atherton’s GP that this process results in delays . This is because the investigations could be undertaken more quickly if the radiologists themselves instigated the necessary additional investigations . This is particularly the case where the suggested investigations cannot actually be requested by GPs . The Trust gave evidence that this process is necessary because of the commissioning arrangements in place, which determine how payment is made for such tests. I am concerned that this process could increase the risk of future deaths occurring in similar circumstances to Mr Atherton’s case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system at the GP practice to ensure successful receipt of important correspondence
Wider context from the report “(1) It was clear from the evidence at the inquest that Mr Atherton’s GP was concerned that he should be seen for orthopaedic review more quickly than had been planned. However, was concerned that, given the importance of this further correspondence, there was no system in place at the GP practice to ensure successful receipt of the fax .
” 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 clinically triage routine orthopaedic referrals
Wider context from the report “(2) I heard evidence that routine ‘choose and book’ orthopaedic referrals are not clinically triaged by the specialist to whom the referrals are made . As such, the concern was raised (which I share) that there is no potential for the triaging of apparently ‘routine’ appointments which, with specialist input might be expedited . It was clear from the evidence heard that other departments routinely triage referrals and no evidence was provided as to why this is not undertaken by the orthopaedic department.
” 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 appropriate safeguards to prevent patients at risk from leaving before capacity assessment
Wider context from the report “(4) The neurosurgical ward from which Mr Atherton self-discharged was not locked. This was despite the risk he posed to himself and the fact that the staff were clear he should not be free to leave, without medical assessment of his capacity to self-discharge . I heard evidence that the current legislative framework and case law means that locking of wards is not acceptable. Whilst it is clear that locking ward doors by default is not appropriate, I did not hear compelling evidence as to why mechanisms could not be put in place to facilitate temporary locking . I am concerned that the legal position is being interpreted so that no appropriate safeguards exist , which would have prevented Mr Atherton from absconding. This raises concerns that future deaths could result in such circumstances, if this issue is not addressed.
” Open source report
29 Aug 2014 Irshad ALI · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 6 Failure to record intentional rounding checks View source Failure to perform neurological observations before discharge View source Failure to complete physiotherapy assessment before discharge View source Failure to communicate pending physiotherapy assessment information View source Failure to record post-fall neurological observations View source Premature issuing of discharge paperwork View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Irshad 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
Irshad Ali was admitted to hospital for drainage of ascites, fell unwitnessed on the ward on 25 March 2014, and later returned with a massive head injury. He died six weeks later following a consequent chest infection. Concerns included missing records of intentional rounding and neurological observations, required pre-discharge checks not being completed, and communication problems around his discharge.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record intentional rounding checks
Wider context from the report “1. The nursing staff should have checked on Mr Ali every two hours through the night, but there was no record of intentional rounding on 24/25 March . There was a record of the night before and a record of the night after, but not the night that Mr Ali fell. The chart appears to have gone missing.
” 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 perform neurological observations before discharge
Wider context from the report “3. The consultant in charge of Mr Ali’s care stipulated that his junior medical colleagues should perform neurological observations before Mr Ali could be discharged, yet this did not take place .
The sister in charge told me that she asked the registrar if Mr Ali was neurologically stable enough to be discharged, and she said yes.
” 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 physiotherapy assessment before discharge
Wider context from the report “4. The consultant in charge of Mr Ali’s care also stipulated that Mr Ali should undergo physiotherapy assessment before he could be discharged, yet this did not take place .
The sister in charge told me that she knew about this and she knew that a physiotherapist was going to review Mr Ali that afternoon. However, she did not pass this information on to the nurse who looked after Mr Ali during the sister’s lunch break, nor to Mr Ali’s family.
The nurse said that she did tell Mr Ali’s family he was not ready for discharge, but she gave them the discharge paperwork before she went for lunch and so they assumed he could go.
Both the doctor and the nurse who gave evidence told me that they now think that discharge packs should not be given out until the patient’s discharge is complete.
” 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 pending physiotherapy assessment information
Wider context from the report “4. The consultant in charge of Mr Ali’s care also stipulated that Mr Ali should undergo physiotherapy assessment before he could be discharged, yet this did not take place.
The sister in charge told me that she knew about this and she knew that a physiotherapist was going to review Mr Ali that afternoon. However, she did not pass this information on to the nurse who looked after Mr Ali during the sister’s lunch break, nor to Mr Ali’s family .
The nurse said that she did tell Mr Ali’s family he was not ready for discharge, but she gave them the discharge paperwork before she went for lunch and so they assumed he could go.
Both the doctor and the nurse who gave evidence told me that they now think that discharge packs should not be given out until the patient’s discharge is complete.
” 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 post-fall neurological observations
Wider context from the report “2. Though the senior sister looking after Mr Ali on the morning of 25 March assured me that neurological observations were carried out hourly after his fall, there was no record of this . Again, the chart appears to have gone missing.
” 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 Premature issuing of discharge paperwork
Wider context from the report “4. The consultant in charge of Mr Ali’s care also stipulated that Mr Ali should undergo physiotherapy assessment before he could be discharged, yet this did not take place.
The sister in charge told me that she knew about this and she knew that a physiotherapist was going to review Mr Ali that afternoon. However, she did not pass this information on to the nurse who looked after Mr Ali during the sister’s lunch break, nor to Mr Ali’s family.
The nurse said that she did tell Mr Ali’s family he was not ready for discharge, but she gave them the discharge paperwork before she went for lunch and so they assumed he could go.
Both the doctor and the nurse who gave evidence told me that they now think that discharge packs should not be given out until the patient’s discharge is complete .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include documentation and falls management in induction for new medical trainees.
Verbatim wording from the response “Senior medical staff have confirmed that the induction for new medical trainees now includes a section on documentation and management of falls, emphasising the requirement to document actions in the medical records.” Source location 2014-0387-Response-by-Barts-Health-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit nurses’ falls-policy understanding, care-plan documentation, neurological-observation understanding, and competence in performing neurological observations.
Verbatim wording from the response “To ensure that the Trust falls protocol is being complied with, twice daily safety briefings will be held to highlight the falls protocol. Nursing staff have been reminded that the nurse in charge of shift has responsibility for ensuring the correct procedure is followed and documented in the medical notes. Training for nurses in neurological observations is being provided by the Critical Care Outreach Team. Effectiveness will be measured by audit of nurses’ understanding of the falls policy and documentation in the care plan, their understanding of neurological observations, and competence in the performance of neurological observations.” Source location 2014-0387-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 Hold twice-daily safety briefings highlighting the Trust falls protocol.
Verbatim wording from the response “To ensure that the Trust falls protocol is being complied with, twice daily safety briefings will be held to highlight the falls protocol. Nursing staff have been reminded that the nurse in charge of shift has responsibility for ensuring the correct procedure is followed and documented in the medical notes. Training for nurses in neurological observations is being provided by the Critical Care Outreach Team. Effectiveness will be measured by audit of nurses’ understanding of the falls policy and documentation in the care plan, their understanding of neurological observations, and competence in the performance of neurological observations.” Source location 2014-0387-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 nurses with neurological-observation training through the Critical Care Outreach Team.
Verbatim wording from the response “To ensure that the Trust falls protocol is being complied with, twice daily safety briefings will be held to highlight the falls protocol. Nursing staff have been reminded that the nurse in charge of shift has responsibility for ensuring the correct procedure is followed and documented in the medical notes. Training for nurses in neurological observations is being provided by the Critical Care Outreach Team. Effectiveness will be measured by audit of nurses’ understanding of the falls policy and documentation in the care plan, their understanding of neurological observations, and competence in the performance of neurological observations.” Source location 2014-0387-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 that the nurse in charge is responsible for following and documenting the correct falls procedure.
Verbatim wording from the response “To ensure that the Trust falls protocol is being complied with, twice daily safety briefings will be held to highlight the falls protocol. Nursing staff have been reminded that the nurse in charge of shift has responsibility for ensuring the correct procedure is followed and documented in the medical notes. Training for nurses in neurological observations is being provided by the Critical Care Outreach Team. Effectiveness will be measured by audit of nurses’ understanding of the falls policy and documentation in the care plan, their understanding of neurological observations, and competence in the performance of neurological observations.” Source location 2014-0387-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 nurses to provide discharge letters only after the discharge process is complete and update patient information sheets accordingly.
Verbatim wording from the response “It is Trust policy that the copy of the patients’ discharge letter should be given once all facets of the discharge process are complete. Nurses have been reminded of the policy and the requirement to update the patient information sheet with the information that the discharge summary should be given to the patient alongside their discharge medications. To facilitate this, the Trust continues to cultivate a continued effective relationship with the Trust discharge lounge.” Source location 2014-0387-Response-by-Barts-Health-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct monthly senior nursing audits of medical-record filing, with spot checks of intentional-rounding compliance and correct filing.
Verbatim wording from the response “During the investigation, senior qualified nursing staff contacted the nurse allocated to care for Mr Ali on the night of 24/15 March 2014, who confirmed that the intentional rounding did take place. The intentional rounding chart for this night remains missing. Evidence has been adduced that this is because the medical notes had been filed incorrectly. This will be dealt with by a monthly senior nursing audit of the integrity of the filing of patients’ notes and spot checks for intentional rounding compliance and correct filing of medical notes.” Source location 2014-0387-Response-by-Barts-Health-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Appropriate neurological observations were carried out after the fall; the missing chart was inadvertently misfiled.
Verbatim wording from the response “The missing neurological observation chart has been located and it confirms that appropriate neurological observations were carried out after Mr Ali’s fall. This chart had been inadvertently misfiled.” Source location 2014-0387-Response-by-Barts-Health-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Intentional rounding occurred despite the missing chart, which resulted from medical notes being filed incorrectly.
Verbatim wording from the response “During the investigation, senior qualified nursing staff contacted the nurse allocated to care for Mr Ali on the night of 24/15 March 2014, who confirmed that the intentional rounding did take place. The intentional rounding chart for this night remains missing. Evidence has been adduced that this is because the medical notes had been filed incorrectly. This will be dealt with by a monthly senior nursing audit of the integrity of the filing of patients’ notes and spot checks for intentional rounding compliance and correct filing of medical notes.” Source location 2014-0387-Response-by-Barts-Health-NHS-Trust
Open published response
7 Aug 2014 Vijay Sonagara · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Failure to incorporate temporary medical records into the permanent file View source Unavailability of potentially relevant information from separate medical records to treating doctors View source Failure to amalgamate or cross-reference medical records held under different hospital numbers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Vijay Sonagara · 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
Vijay Sonagara, who had alcoholic liver disease, underwent routine surgery for repair of an inguinal hernia on 8 February 2013. His condition deteriorated rapidly, and he died at St Thomas’ Hospital on 22 February 2013 after developing decompensated alcoholic liver disease requiring intensive care. The concerns were that medical records were held under different hospital numbers and in a temporary file, were not amalgamated or cross-referenced, and contained potentially relevant information that was unavailable to his treating doctors.
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 incorporate temporary medical records into the permanent file
Wider context from the report “My concerns are therefore as follows:
(1) Mr Sonagara had two different sets of medical records under two different hospital numbers that were not amalgamated or cross referenced.
(2) In addition a third temporary file of medical records was not incorporated into the permanent file .
(3) Potentially relevant information contained in the second and third set of records was not available to Mr Sonagara’s treating doctors.
” 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 potentially relevant information from separate medical records to treating doctors
Wider context from the report “My concerns are therefore as follows:
(1) Mr Sonagara had two different sets of medical records under two different hospital numbers that were not amalgamated or cross referenced.
(2) In addition a third temporary file of medical records was not incorporated into the permanent file.
(3) Potentially relevant information contained in the second and third set of records was not available to Mr Sonagara’s treating doctors .
” 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 amalgamate or cross-reference medical records held under different hospital numbers
Wider context from the report “My concerns are therefore as follows:
(1) Mr Sonagara had two different sets of medical records under two different hospital numbers that were not amalgamated or cross referenced .
(2) In addition a third temporary file of medical records was not incorporated into the permanent file.
(3) Potentially relevant information contained in the second and third set of records was not available to Mr Sonagara’s treating doctors.
” Open source report
24 Jan 2014 Bertha CRAY · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Failure to elucidate the cause of alteration of ‘nil by mouth’ signage View source Failure to take action following a clinical incident involving ‘nil by mouth’ signage View source Failure to prevent inadvertent alteration of ‘nil by mouth’ signage View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Bertha CRAY · 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
Bertha CRAY’s oesophagus was perforated during an upper-gastrointestinal endoscopy, and she later died from bronchopneumonia resulting from the perforation and surgical treatment. The report raised concerns about the possible inadvertent alteration or replacement of ‘nil by mouth’ signage, uncertainty about how this occurred, and the lack of demonstrated action following the incident investigation.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to elucidate the cause of alteration of ‘nil by mouth’ signage
Wider context from the report “(2) On the account provided by the family, the ‘nil by mouth’ sign was replaced by some other means. The cause of this alteration is unclear , owing to the focus of the incident form being the ‘double-sided’ account , provided by the nursing staff. As such, it is possible that there could be a recurrence of this incident, as the cause has not been elucidated .
” 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 take action following a clinical incident involving ‘nil by mouth’ signage
Wider context from the report “(1) On the account provided by the nursing staff, it is possible that inadvertent alteration of ‘nil by mouth’ signage could occur in the future, due to the apparent ease with which a double-sided sign can be turned and lack of action taken as a consequence of this clinical incident .
” 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 prevent inadvertent alteration of ‘nil by mouth’ signage
Wider context from the report “(1) On the account provided by the nursing staff, it is possible that inadvertent alteration of ‘nil by mouth’ signage could occur in the future , due to the apparent ease with which a double-sided sign can be turned and lack of action taken as a consequence of this clinical incident.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review processes to enhance future care.
Verbatim wording from the response “We have taken this as an opportunity to review our processes to enhance future care. The family has been informed of the outcome of the investigation and reassured by the changes made by the Trust.” Source location 2014-0037-Response-by-Barts-Health-NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Stop using amendable double-sided nil-by-mouth signs and issue signs carrying the same instruction on both sides.
Verbatim wording from the response “During the investigation, qualified nursing staff confirmed that the use of double-sided ‘nil-by-mouth’/‘sips of water’ signs at the bedside was not the usual practice in the Trust. In this particular case, ‘sips of water’ had been written on the other side of the sign. This practice will now stop and new signs issued with the same instruction on both sides, so there is no option to amend the signs by writing on them.” Source location 2014-0037-Response-by-Barts-Health-NHS
Open published response
19 Jan 2014 Gregg O’REILLY · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Failure to record required patient observations View source Failure to refer patients to critical care when appropriate View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Gregg O’REILLY · 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
Gregg O’Reilly was admitted as an emergency with dehydration, poor nutritional state, high stoma output, acute kidney injury and a high white cell count. He later developed multi-organ failure and repeated bleeding from his abdominal wound, but did not recover after surgery and critical care admission. The report raised concerns that he was not referred to critical care by 17.01.14 and that no observation records could be found between midnight and 3am before his second bleed and cardiac arrest call.
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 required patient observations
Wider context from the report “Further, although he was on two hourly observations, no record of any observation could be found between midnight on 17.01.14 and 3am on 18.01.14 , when Mr O’Reilly was found to have suffered a second bleed with very low blood pressure, and a cardiac arrest call was made.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Barts Health NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to refer patients to critical care when appropriate
Wider context from the report “I heard that an opportunity was missed by the medical, ward nursing and critical care nursing outreach teams, to refer Mr O’Reilly to critical care , certainly by 17.01.14. It is unclear whether that would have changed the outcome for him, but it meant that he was not offered optimal care . Given the number of staff who could have made such a referral, it seems that this issue goes further than individual error or lack of understanding . I appreciate that also makes it a big issue to tackle.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Launch an education strategy and incorporate deteriorating-patient recognition and response into medical and nursing induction.
Verbatim wording from the response “10. Launch an Education Strategy to ensure all staff can identify a sick and deteriorating patient and can escalate concerns. The Trust medical and nursing Induction Programmes to incorporate a briefing on ‘Recognising and Responding to the Deteriorating Patient.’” Source location 2014-0221-Response-by-Barts-Health-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop formal guidelines specifying when the Critical Care Outreach Team should request critical-care medical review.
Verbatim wording from the response “5. The Critical Care Outreach Team (CCOT) and the consultant intensivists to develop formal guidelines, outlining when CCOT should request a critical care medical review.” Source location 2014-0221-Response-by-Barts-Health-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate cardiac-arrest audit findings, agree action plans and involve relevant groups in delivering recommendations.
Verbatim wording from the response “11. The Trust is planning an "all site" Cardiac Arrest Call Audit in July 2014 to determine what factors pre-empted the call and to look at whether appropriate care was taking place prior to the arrest. Ensure the findings are widely disseminated, action plans agreed, and all key groups mentioned above are involved in delivering the key recommendations.” Source location 2014-0221-Response-by-Barts-Health-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete the transition to electronic patient records and register and mitigate risks from the interim hybrid system.
Verbatim wording from the response “3. Ensure the transition period from a paper based system to the full electronic patient record is as short as possible and ensure the risks of the hybrid system are on the Risk Register and appropriate mitigation is in place.” Source location 2014-0221-Response-by-Barts-Health-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct an all-site cardiac-arrest call audit examining pre-arrest factors and care provided before arrests.
Verbatim wording from the response “11. The Trust is planning an "all site" Cardiac Arrest Call Audit in July 2014 to determine what factors pre-empted the call and to look at whether appropriate care was taking place prior to the arrest. Ensure the findings are widely disseminated, action plans agreed, and all key groups mentioned above are involved in delivering the key recommendations.” Source location 2014-0221-Response-by-Barts-Health-NHS-Trust
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations