PFD report

Thomas Doyle · Prevention of Future Deaths report

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Issued 20 Oct 2023•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
2

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
15

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. Poor standard of clinical records
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
  2. Failure to commence a diagnostic pathway for suspected sepsis when indicated
    Part of recurring concern: Failure to reliably recognise and respond promptly to sepsis
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.8

  1. Action

    Provide regular weekly sepsis teaching sessions in Acute Medicine across both sites.

    Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 31 October 2023.
  2. Action

    Audit electronic sepsis-suspicion documentation monthly and report compliance through established assurance arrangements.

    Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 31 October 2023.
  3. Action

    Update the Trust sepsis education programme and provide additional face-to-face training for doctors and nurses.

    Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 31 October 2023.

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 standard of clinical records

Wider context from the report

“1. The trust’s clinical records were of a particularly poor standard which impeded the Trust’s governance investigation and the inquest investigation in determining what, if any considerations was given to the possibility that Mr Doyle was suffering from an infection. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to commence a diagnostic pathway for suspected sepsis when indicated

Wider context from the report

“2. The Trust’s failure to commence a diagnostic pathway to investigate sepsis when clearly indicated on Mr Doyle’s admission, as required by both local policy and national guidance. ”

Is this part of a recurring concern?

Yes — Failure to reliably recognise and respond promptly to sepsis.

Open source report

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Provide regular weekly sepsis teaching sessions in Acute Medicine across both sites.

Verbatim wording from the response

“• Acute Medicine have regular weekly teaching sessions within which sepsis is the most regular topic on both sites.”

Source location

Response from Barking, Havering and Redbridge University Hospitals NHS Trust
Page 2 · response
Published 31 October 2023

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 electronic sepsis-suspicion documentation monthly and report compliance through established assurance arrangements.

Verbatim wording from the response

“• There is a mandatory field on the new electronic record asking the question 'is sepsis suspected' if yes this triggers the sepsis pathway and data is captured that way. Monthly audit of this takes place with the latest results showing 100% compliance of the records audited.”

Source location

Response from Barking, Havering and Redbridge University Hospitals NHS Trust
Page 2 · response
Published 31 October 2023

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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

Update the Trust sepsis education programme and provide additional face-to-face training for doctors and nurses.

Verbatim wording from the response

“• The Trust sepsis education programme is essential for all clinical staff and has recently been updated. This is supported by additional face to face training for doctors and nurses.”

Source location

Response from Barking, Havering and Redbridge University Hospitals NHS Trust
Page 2 · response
Published 31 October 2023

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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 and report an Emergency Department medical-records audit of Careflow free-text completion, with oversight by the Trust Audit Committee.

Verbatim wording from the response

“• ED services have registered a medical records audit which will commence December 2023 and complete 31 January 2024, on the new electronic Careflow record, ensuring the free text sections are being completed to the Trust and professional standards. The audit report will be shared with all teams and action plan agreed for any identified areas of concern; the audit will be overseen by the Trust Audit Committee.”

Source location

Response from Barking, Havering and Redbridge University Hospitals NHS Trust
Page 2 · response
Published 31 October 2023

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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

Adopt the UK Sepsis Trust adult screening tool and audit its use, high-risk patients and positive blood-culture compliance with the Sepsis 6.

Verbatim wording from the response

“• The Trust has adopted the UK Sepsis Trust’s adult screening tool and the use of this is audited by the Lead Nurse for Sepsis. Audits include patients who have scored over 5 on the National Early Warning Score to ensure that Sepsis was considered. In addition, all positive blood culture cases are audited to ensure compliance with the Sepsis 6.”

Source location

Response from Barking, Havering and Redbridge University Hospitals NHS Trust
Page 2 · response
Published 31 October 2023

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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

Use a mandatory electronic sepsis-suspicion field that triggers the sepsis pathway and captures compliance data.

Verbatim wording from the response

“• There is a mandatory field on the new electronic record asking the question 'is sepsis suspected' if yes this triggers the sepsis pathway and data is captured that way. Monthly audit of this takes place with the latest results showing 100% compliance of the records audited.”

Source location

Response from Barking, Havering and Redbridge University Hospitals NHS Trust
Page 2 · response
Published 31 October 2023

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 medical staff record-keeping e-learning from their first working day and include record keeping in nursing preceptorship and junior-doctor induction.

Verbatim wording from the response

“• All medical staff must complete a record keeping module on the Trust BEST learning management system that allows staff to undertake e learning module on their first day working at the Trust. Record keeping for nursing staff is included in the nursing preceptorship programme.”

Source location

Response from Barking, Havering and Redbridge University Hospitals NHS Trust
Page 2 · response
Published 31 October 2023

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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 record-keeping standards and safety concerns through staff alerts, intranet video, computer screensavers and clinical governance meetings.

Verbatim wording from the response

“• An Internal Alert has been shared with staff via email, Alert reference ████████ Issued Date 9 November 2023 which details good record keeping standards that should be adhered to by all staff.”

Source location

Response from Barking, Havering and Redbridge University Hospitals NHS Trust
Page 1 · response
Published 31 October 2023

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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

    Implement Martha's Rule across at least 100 acute or specialist NHS sites in England.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 31 October 2023.
  2. 2

    Provide monthly Trust sepsis-group oversight of sepsis management.

    Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 31 October 2023.
  3. 3

    Conduct monthly clinical-area assurance walkabouts, share findings and learning through speciality meetings and staff safety briefings, and provide access for temporary workers.

    Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 31 October 2023.
  4. 4

    Engage Clinical Group Directors on PFD concerns and request named-clinician attendance at the Trust Sepsis Group.

    Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 31 October 2023.
  5. 5

    Operate the Ward Accreditation framework through multidisciplinary assessments, accreditation awards and Trust-wide improvement learning.

    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 31 October 2023.
  6. 6

    Conduct rolling external and internal sepsis mortality reviews and present their findings to the Sepsis Steering Committee every two months.

    Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 31 October 2023.
  7. 7

    Conduct monthly antimicrobial prescribing audits to monitor compliance with sepsis treatment standards.

    Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 31 October 2023.

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 Martha's Rule across at least 100 acute or specialist NHS sites in England.

Verbatim wording from the response

“Finally, in February the Government and NHS England announced plans to implement Martha’s Rule in at least 100 acute or specialist NHS sites in England by March 2025. Martha’s Rule is an initiative that gives patients and their families who are concerned about deterioration in their physiological condition the right to initiate a rapid review of their case 24”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 31 October 2023

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 monthly Trust sepsis-group oversight of sepsis management.

Verbatim wording from the response

“• Monthly sepsis group oversight of sepsis management”

Source location

Response from Barking, Havering and Redbridge University Hospitals NHS Trust
Page 3 · response
Published 31 October 2023

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 monthly clinical-area assurance walkabouts, share findings and learning through speciality meetings and staff safety briefings, and provide access for temporary workers.

Verbatim wording from the response

“• Monthly assurance walkabouts in clinical areas; the audit is completed monthly on both sites by the band 7 nurses, they audit 10 sets of notes each month selected from patients who present with primary mental health presentation. The audit comprises of a variety of questions that monitor aspects of care including if safeguarding referrals have been made, risk assessments completed, nursing care risk assessments have been completed, incident report for rapid tranquilisation and compliance with enhanced observations. Matrons oversee the audits, results, and actions. Audit results are shared monthly at the speciality meeting and learning is shared between the two Emergency Departments. This is minuted in the meetings. Learning for the individual departments is shared with the staff through their daily safety brief which takes place at the twice daily huddle.”

Source location

Response from Barking, Havering and Redbridge University Hospitals NHS Trust
Page 2 · response
Published 31 October 2023

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

Engage Clinical Group Directors on PFD concerns and request named-clinician attendance at the Trust Sepsis Group.

Verbatim wording from the response

“• The Medical Director has discussed PFD concerns with the Clinical Group Directors and requested they ensure attendance of named clinicians to attend the Trust Sepsis Group.”

Source location

Response from Barking, Havering and Redbridge University Hospitals NHS Trust
Page 1 · response
Published 31 October 2023

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Operate the Ward Accreditation framework through multidisciplinary assessments, accreditation awards and Trust-wide improvement learning.

Verbatim wording from the response

“• The BHRUT Ward Accreditation framework is bespoke although informed by learning from other trusts. It involves reviewing processes, procedures and systems which support excellence. Every ward has a different journey, based on the findings of initial assessments. Issues that form collective challenges can be identified and inform Trust-wide improvement efforts. Benefits of the programme include: ○ reducing unwarranted variation by providing an evidence-based, standardised approach to supporting the delivery of care and improving quality ○ helping staff understand what is expected at ward level by providing a clear set of standards and a measure of how well they are doing in delivering quality care ○ improving patient outcomes and experience ○ recognition and appreciation for those teams that receive an accreditation award ○ Increased teamwork across BHRUT.”

Source location

Response from Barking, Havering and Redbridge University Hospitals NHS Trust
Page 3 · response
Published 31 October 2023

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 rolling external and internal sepsis mortality reviews and present their findings to the Sepsis Steering Committee every two months.

Verbatim wording from the response

“• Sepsis mortality reviews are scheduled on a rolling basis. The raw data is sent externally to a central review body in Birmingham. The data is analyzed with internationally accepted health modelling data to see if mortality rates are in keeping with that expected for the case mix in the hospital catchment area. These do not indicate failings in care but help each Trust to examine their processes.”

Source location

Response from Barking, Havering and Redbridge University Hospitals NHS Trust
Page 2 · response
Published 31 October 2023

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 monthly antimicrobial prescribing audits to monitor compliance with sepsis treatment standards.

Verbatim wording from the response

“• The Antimicrobial Point Prevention Audit for October 2023 shows MAU KGH achieved 100% which reflects the teaching and learning of the staff. This is a monthly audit.”

Source location

Response from Barking, Havering and Redbridge University Hospitals NHS Trust
Page 2 · response
Published 31 October 2023

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