PFD report

Elizabeth Margaret Mills · Prevention of Future Deaths report

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Issued 25 May 2022•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.

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Concerns
5

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

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 raised5

  1. Failure to explore family members’ views during the do-not-attempt-CPR process
  2. Poor medical record-keeping and documentation of do-not-attempt-CPR decisions
    Part of recurring concern: Unreliable DNACPR decision-making, recording and communication
  3. Failure to properly engage the do-not-attempt-CPR process
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.2

  1. Action

    Remind nursing staff of expectations for safely caring for patients receiving oxygen therapy.

    Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 16 September 2022.
  2. Action

    Ratify a new DNACPR policy.

    Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 16 September 2022.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    The current DNACPR policy sufficiently requires communication, documentation and regular review of CPR decisions.

    Stated by Barking, Havering and Redbridge University Hospitals NHS TrustExisting 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 explore family members’ views during the do-not-attempt-CPR process

Wider context from the report

“1. The poor standard of medical record-keeping and documentation did not allow a clear understanding of whether the Trust policy on “Do not attempt CPR” orders was followed properly. Family members assert that the process was not properly engaged and their views were not explored. ”

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

Poor medical record-keeping and documentation of do-not-attempt-CPR decisions

Wider context from the report

“1. The poor standard of medical record-keeping and documentation did not allow a clear understanding of whether the Trust policy on “Do not attempt CPR” orders was followed properly. Family members assert that the process was not properly engaged and their views were not explored. ”

Is this part of a recurring concern?

Yes — Unreliable DNACPR decision-making, recording and communication.

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 to properly engage the do-not-attempt-CPR process

Wider context from the report

“1. The poor standard of medical record-keeping and documentation did not allow a clear understanding of whether the Trust policy on “Do not attempt CPR” orders was followed properly. Family members assert that the process was not properly engaged and their views were not explored. ”

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 to investigate unexpected care-impacting events through Serious Incident Investigation

Wider context from the report

“3. Unexpected events that impacted upon Mrs Mills’ care were not investigated by the Trust in the form of a Serious Incident Investigation. ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations; Unreliable formal safety-incident management processes.

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

Reliance on a family member to maintain oxygen mask placement

Wider context from the report

“2. During the final hours of her life, Mrs Mills required increasing levels of oxygen therapy. Mrs Mills was agitated and repeatedly removed her venturi mask. Medical and nursing staff left Mrs Mills in a side ward in the care of her husband, relying upon him to ensure her mask remained in place. ”

Is this part of a recurring concern?

Yes — Failure to safely supervise patients receiving oxygen therapy.

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 staff of expectations for safely caring for patients receiving oxygen therapy.

Verbatim wording from the response

“The expectation is that if a nurse leaves the patient, they will notify the patient/relative/visitor of where they are going, how long they will be and to call, if assistance is required. Nursing staff will be reminded of the expectations involved in nursing patients receiving oxygen therapy.”

Source location

Response from NHS Barking, Havering and Redbridge University Hospital
Page 3 · response
Published 16 September 2022

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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

Ratify a new DNACPR policy.

Verbatim wording from the response

“The Trust is satisfied that the current policy (attached to this response) clearly sets out the need for clear communication about DNACPR with the patient and those close to them, together with the need for clear documentation on DNACPR decisions and the requirement for regular review of DNACPR decisions. I am sorry that the documentation in this case did not allow a clear understanding of whether the Trust policy on DNACPR orders was correctly followed. The Trust intends to ratify a new DNACPR policy in August 2022. Policies undergo rigorous drafting with stakeholder engagement, to aid richer development. Policies are disseminated across the Trust in discussion by virtual meetings, relevant forums such as Quality and Safety meetings, emails cascaded by Divisional teams and through briefings by the Communications Team.”

Source location

Response from NHS Barking, Havering and Redbridge University Hospital
Page 2 · response
Published 16 September 2022

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

The current DNACPR policy sufficiently requires communication, documentation and regular review of CPR decisions.

Verbatim wording from the response

“The Trust is satisfied that the current policy (attached to this response) clearly sets out the need for clear communication about DNACPR with the patient and those close to them, together with the need for clear documentation on DNACPR decisions and the requirement for regular review of DNACPR decisions. I am sorry that the documentation in this case did not allow a clear understanding of whether the Trust policy on DNACPR orders was correctly followed. The Trust intends to ratify a new DNACPR policy in August 2022. Policies undergo rigorous drafting with stakeholder engagement, to aid richer development. Policies are disseminated across the Trust in discussion by virtual meetings, relevant forums such as Quality and Safety meetings, emails cascaded by Divisional teams and through briefings by the Communications Team.”

Source location

Response from NHS Barking, Havering and Redbridge University Hospital
Page 2 · response
Published 16 September 2022

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

The incident did not require a Serious Incident investigation because reviews concluded it was not a Serious Incident matter.

Verbatim wording from the response

“The incident was reported on 26 March 2021 and it was flagged as a potential SI matter by the Quality and Safety ‘Q&S’ Team. A review was undertaken by the ED Matron and by the Surgical Division. This was held with multidisciplinary key stakeholders from including pharmacists, matrons, registrars, clinical leads, consultants and consultant surgeons from Gastroenterology, Breast and General Surgery, Adult Day Unit and Theatres. The reviews established that the correct morphine doses were given to EM at appropriate times and the matter was not an SI matter. The Q&S team removed the potential SI flag. Separately, EM’s husband pursued a complaint regarding her care and management which was not upheld and the husband declined a meeting with the Trust.”

Source location

Response from NHS Barking, Havering and Redbridge University Hospital
Page 3 · response
Published 16 September 2022

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

In acute deterioration, it may not be possible to provide additional staff to supervise a patient removing oxygen therapy.

Verbatim wording from the response

“care to assist with giving oxygen therapy safely. However, in an acute situation, such as EM’s situation, where the patient deteriorates quickly, it may not be possible to facilitate extra staff and the focus would be on providing immediate treatment. It is expected that nursing staff would escalate the fact that a patient is agitated and removing their oxygen mask to the doctor/nurse in charge. It would be reasonable for a nurse to leave the patient for a short period in order to communicate with colleagues/escalate any concerns, if the patient was settled. Patients’ relatives can be very helpful in reassuring and calming patients to assist with giving therapies such as oxygen but there would not be an assumption that they would deal with administering the therapy.”

Source location

Response from NHS Barking, Havering and Redbridge University Hospital
Page 3 · response
Published 16 September 2022

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.3

  1. 1

    Implement a Medical Examiners team to scrutinise deaths not initially investigated by the Coroner.

    Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 16 September 2022.
  2. 2

    Conduct an independent mortality review for all new inquests.

    Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 September 2022.
  3. 3

    Report all new inquests to formalise divisional review.

    Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 September 2022.

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Implement a Medical Examiners team to scrutinise deaths not initially investigated by the Coroner.

Verbatim wording from the response

“The Trust teams considered that the incident did not require escalation to SI, as morphine was given, EM had respiratory distress and responded to opioid antidotes, leading to the impression of opioid sensitivity. I trust this clarifies why the Trust did not undertake an SI investigation. The Trust has already introduced incident reporting of all new inquests to formalise divisional review. It has also introduced an independent mortality review for all new inquests. A Medical Examiners team is being implemented across the Trust to ensure scrutiny of deaths, not investigated at the outset by the Coroner, to provide further reassurance regarding the appropriate investigation of deaths at the Trust.”

Source location

Response from NHS Barking, Havering and Redbridge University Hospital
Page 3 · response
Published 16 September 2022

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 an independent mortality review for all new inquests.

Verbatim wording from the response

“The Trust teams considered that the incident did not require escalation to SI, as morphine was given, EM had respiratory distress and responded to opioid antidotes, leading to the impression of opioid sensitivity. I trust this clarifies why the Trust did not undertake an SI investigation. The Trust has already introduced incident reporting of all new inquests to formalise divisional review. It has also introduced an independent mortality review for all new inquests. A Medical Examiners team is being implemented across the Trust to ensure scrutiny of deaths, not investigated at the outset by the Coroner, to provide further reassurance regarding the appropriate investigation of deaths at the Trust.”

Source location

Response from NHS Barking, Havering and Redbridge University Hospital
Page 3 · response
Published 16 September 2022

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Report all new inquests to formalise divisional review.

Verbatim wording from the response

“The Trust teams considered that the incident did not require escalation to SI, as morphine was given, EM had respiratory distress and responded to opioid antidotes, leading to the impression of opioid sensitivity. I trust this clarifies why the Trust did not undertake an SI investigation. The Trust has already introduced incident reporting of all new inquests to formalise divisional review. It has also introduced an independent mortality review for all new inquests. A Medical Examiners team is being implemented across the Trust to ensure scrutiny of deaths, not investigated at the outset by the Coroner, to provide further reassurance regarding the appropriate investigation of deaths at the Trust.”

Source location

Response from NHS Barking, Havering and Redbridge University Hospital
Page 3 · response
Published 16 September 2022

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