PFD report

Evadney Dawkins · Prevention of Future Deaths report

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Issued 21 Dec 2020•East London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
2

Raised in this report

Recipients
3

Named on the report

Responses found
2

Of 3 recipients

Stated actions
16

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Failure to undertake required renal monitoring
  2. Failure of governance systems to assess cases as Serious Incidents requiring investigation
    Part of recurring concern: Unreliable formal safety-incident management processes
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.9

  1. Action

    Use electronic records for integrated patient documentation, automated fluid input/output recording and alerts when safety parameters are breached.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 January 2021.
  2. Action

    Appoint three Medical Examiners to review every death on the site.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 January 2021.
  3. Action

    Add a supported database to monitor acute kidney injury patients and compliance with the bundle.

    Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 8 January 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Existing Trust systems, including multidisciplinary death reviews and medical examiner scrutiny, are considered sufficient to prevent recurrence of missed Serious Incident identification.

    Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Unreliable formal safety-incident management processes.

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
Page 2 · response
Published 8 January 2021

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
Page 2 · response
Published 8 January 2021

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
Page 1 · response
Published 8 January 2021

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
Page 1 · response
Published 8 January 2021

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
Page 1 · response
Published 8 January 2021

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
Page 1 · response
Published 8 January 2021

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
Page 2 · response
Published 8 January 2021

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
Page 1 · response
Published 8 January 2021

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
Page 2 · response
Published 8 January 2021

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 Trust systems, including multidisciplinary death reviews and medical examiner scrutiny, are considered sufficient to prevent recurrence of missed Serious Incident identification.

Verbatim wording from the response

“I understand the Trust has acknowledged the failure to identify Mrs Dawkins death as a Serious Incident but that it considers that it now has systems in place that mean this is unlikely to happen again. For example, the Trust advises that a multi-disciplinary team now considers unexpected deaths to determine whether investigation under the Serious Incident Review process is appropriate. Additionally, the Trust has appointed three Medical Examiners who review every death within the Trust’s services. As you will know, medical examiners have been introduced to the NHS nationally to provide a new level of independent scrutiny of deaths. Furthermore, the Trust has created a new post of Deputy Medical Director with a remit to provide greater assurance on patient safety governance.”

Source location

2020-0292-Response-from-Dept.-of-Health-Social-Care-Redacted
Page 2 · response
Published 8 January 2021

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.7

  1. 1

    Hold a daily operations-hub huddle to hand over patients of particular concern.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 January 2021.
  2. 2

    Use standardised ward handover templates for nursing handover.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 January 2021.
  3. 3

    Conduct daily doctor handovers led by the senior doctor present in a dedicated room.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 January 2021.
  4. 4

    Undertake multidisciplinary simulation training to improve communication.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 January 2021.
  5. 5

    Recruit to posts supporting daily Consultant ward rounds.

    Stated by Barts Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 January 2021.
  6. 6

    Provide compulsory simulation training for Foundation and Core Medical trainees on recognising and treating deteriorating patients.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 January 2021.
  7. 7

    Require NHS trusts to publish quarterly deaths data and annual evidence of learning and preventive actions in Quality Accounts.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 8 January 2021.

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 a daily operations-hub huddle to hand over patients of particular concern.

Verbatim wording from the response

“Regarding nursing handover, standardised ward handover templates have been developed and are in use. In terms of handover for doctors, these are now run by the most senior doctor present; they happen daily and there is a dedicated room for them to happen to avoid disturbances. Support for daily Consultant ward rounds has been agreed; recruitment to these posts is in process. There is also a huddle meeting in the operations hub each morning which gives an opportunity to hand over patients of particular concern. Furthermore we have undertaken simulation training with the whole MDT to improve communication.”

Source location

2020-0292-Response-from-Royal-London-Hospital-Redacted
Page 2 · response
Published 8 January 2021

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 standardised ward handover templates for nursing handover.

Verbatim wording from the response

“Regarding nursing handover, standardised ward handover templates have been developed and are in use. In terms of handover for doctors, these are now run by the most senior doctor present; they happen daily and there is a dedicated room for them to happen to avoid disturbances. Support for daily Consultant ward rounds has been agreed; recruitment to these posts is in process. There is also a huddle meeting in the operations hub each morning which gives an opportunity to hand over patients of particular concern. Furthermore we have undertaken simulation training with the whole MDT to improve communication.”

Source location

2020-0292-Response-from-Royal-London-Hospital-Redacted
Page 2 · response
Published 8 January 2021

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 daily doctor handovers led by the senior doctor present in a dedicated room.

Verbatim wording from the response

“Regarding nursing handover, standardised ward handover templates have been developed and are in use. In terms of handover for doctors, these are now run by the most senior doctor present; they happen daily and there is a dedicated room for them to happen to avoid disturbances. Support for daily Consultant ward rounds has been agreed; recruitment to these posts is in process. There is also a huddle meeting in the operations hub each morning which gives an opportunity to hand over patients of particular concern. Furthermore we have undertaken simulation training with the whole MDT to improve communication.”

Source location

2020-0292-Response-from-Royal-London-Hospital-Redacted
Page 2 · response
Published 8 January 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Undertake multidisciplinary simulation training to improve communication.

Verbatim wording from the response

“Regarding nursing handover, standardised ward handover templates have been developed and are in use. In terms of handover for doctors, these are now run by the most senior doctor present; they happen daily and there is a dedicated room for them to happen to avoid disturbances. Support for daily Consultant ward rounds has been agreed; recruitment to these posts is in process. There is also a huddle meeting in the operations hub each morning which gives an opportunity to hand over patients of particular concern. Furthermore we have undertaken simulation training with the whole MDT to improve communication.”

Source location

2020-0292-Response-from-Royal-London-Hospital-Redacted
Page 2 · response
Published 8 January 2021

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 to posts supporting daily Consultant ward rounds.

Verbatim wording from the response

“Regarding nursing handover, standardised ward handover templates have been developed and are in use. In terms of handover for doctors, these are now run by the most senior doctor present; they happen daily and there is a dedicated room for them to happen to avoid disturbances. Support for daily Consultant ward rounds has been agreed; recruitment to these posts is in process. There is also a huddle meeting in the operations hub each morning which gives an opportunity to hand over patients of particular concern. Furthermore we have undertaken simulation training with the whole MDT to improve communication.”

Source location

2020-0292-Response-from-Royal-London-Hospital-Redacted
Page 2 · response
Published 8 January 2021

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 compulsory simulation training for Foundation and Core Medical trainees on recognising and treating deteriorating patients.

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
Page 1 · response
Published 8 January 2021

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 NHS trusts to publish quarterly deaths data and annual evidence of learning and preventive actions in Quality Accounts.

Verbatim wording from the response

“From 2017-18, we have required NHS trusts to publish locally the numbers of deaths thought to be due to problems in care on a quarterly basis, and to evidence what they have learned and the actions taken to prevent such deaths on an annual basis in their Quality Accounts. This new level of transparency is fundamental to a culture of learning and ensuring the safety of NHS services. This policy is supported by strengthened inspection assessment of NHS trust’s learning from deaths by the CQC.”

Source location

2020-0292-Response-from-Dept.-of-Health-Social-Care-Redacted
Page 2 · response
Published 8 January 2021

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026