PFD report

Jennifer Ruth Whinney · Prevention of Future Deaths report

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Issued 27 Nov 2023•Inner North 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
3

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
26

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 raised3

  1. Lack of assigned responsibility for ensuring that patient notes are sent to external appointments
  2. Failure to ensure that patient notes accompany external appointments
    Part of recurring concern: Failure to reliably transfer medical records between healthcare organisations
  3. Poor maintenance of PICC lines
    Part of recurring concern: Unsafe management of central venous catheters
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.10

  1. Action

    Digitise medical notes across hospital sites to enable seamless transfer of records between digitally enabled hospitals.

    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 1 December 2023.
  2. Action

    Revise and approve the external patient transfer policy, including handover responsibility, a transfer checklist, receipt signatures, and a minimum medical-information dataset.

    Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 1 December 2023.
  3. Action

    Review the process for sending patient notes to external hospital appointments and identify governance gaps.

    Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 1 December 2023.

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

  1. Position

    A comprehensive Serious Incident investigation was not considered necessary because the clinical timeline did not warrant it; events were investigated locally.

    Stated by Barts Health NHS TrustNo action considered necessaryThe respondent said that 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

Lack of assigned responsibility for ensuring that patient notes are sent to external appointments

Wider context from the report

“Jennifer was referred to the colorectal specialist team at the Royal London Hospital and seen in late May. The witnesses were unable to give me the exact date of the appointment. Jennifer’s notes were not sent to the appointment with her. I heard that patient records at Queens Hospital are not electronic. Ward staff compile the notes which are sent physically with the patient if they attend any external appointment. I heard that no one person has responsibility for ensuring that the notes are sent. Jennifer was articulate and understood her health problems well and so was able to provide the colorectal surgeon with her medical background. I am concerned that another patient may not be able to provide such a full and accurate history and that critical information may not be passed on. ”

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 ensure that patient notes accompany external appointments

Wider context from the report

“Jennifer was referred to the colorectal specialist team at the Royal London Hospital and seen in late May. The witnesses were unable to give me the exact date of the appointment. Jennifer’s notes were not sent to the appointment with her. I heard that patient records at Queens Hospital are not electronic. Ward staff compile the notes which are sent physically with the patient if they attend any external appointment. I heard that no one person has responsibility for ensuring that the notes are sent. Jennifer was articulate and understood her health problems well and so was able to provide the colorectal surgeon with her medical background. I am concerned that another patient may not be able to provide such a full and accurate history and that critical information may not be passed on. ”

Is this part of a recurring concern?

Yes — Failure to reliably transfer medical records between healthcare organisations.

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 maintenance of PICC lines

Wider context from the report

“Whilst at the Royal London Hospital Jennifer had at least 6 episodes of sepsis from infected PICC lines. I heard evidence that these infections were contributed to by poor PICC line maintenance. and that the consultant colorectal surgeon raised concerns about the number of PICC line infections that Jennifer and other patients on the ward were getting. I heard some evidence about steps that had been taken but I was told that it was a nursing issue and I only heard evidence from a surgeon. I did not receive any written evidence about changes that have been made. ”

Is this part of a recurring concern?

Yes — Unsafe management of central venous catheters.

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

Digitise medical notes across hospital sites to enable seamless transfer of records between digitally enabled hospitals.

Verbatim wording from the response

“3. The Trust is currently embarking upon its journey into digitisation of medical notes which should be completed in mid-late 2025. Once this is completed it is envisaged that the issue of medical notes being sent between hospital sites, that are also digitally enabled should be seamless; although it is recognised this is a lengthy timescale.”

Source location

Response from Barking, Havering and Redbridge University Hospitals NHS Trust
Page 2 · response
Published 1 December 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

Revise and approve the external patient transfer policy, including handover responsibility, a transfer checklist, receipt signatures, and a minimum medical-information dataset.

Verbatim wording from the response

“1. A review of the process for sending patients notes accompanying them to external hospital visits has been undertaken and we have identified gaps in the governance of this. The policy has now been revised internally and the updated policy, was approved at the Policy Ratification Group that took place today, on 22 January 2024. The changes include both implicit responsibility of handing the patients notes over to the nurse / medical escort or ambulance driver as appropriate, a checklist for the transfer of patients externally as well as a signature section to acknowledge receipt of the notes. A copy of this policy is included with this response for His Majesty’s Coroner’s kind review.”

Source location

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

Review the process for sending patient notes to external hospital appointments and identify governance gaps.

Verbatim wording from the response

“1. A review of the process for sending patients notes accompanying them to external hospital visits has been undertaken and we have identified gaps in the governance of this. The policy has now been revised internally and the updated policy, was approved at the Policy Ratification Group that took place today, on 22 January 2024. The changes include both implicit responsibility of handing the patients notes over to the nurse / medical escort or ambulance driver as appropriate, a checklist for the transfer of patients externally as well as a signature section to acknowledge receipt of the notes. A copy of this policy is included with this response for His Majesty’s Coroner’s kind review.”

Source location

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

Improve nursing and ward-housekeeper staffing and retention to support line management and infection prevention.

Verbatim wording from the response

“In the summer of 2022, prior to Ms Whinney’s death, the surgical nursing leadership team implemented an improvement programme for the management of lines. This included a number of workstreams including:”

Source location

Response from Barts Health NHS Trust
Page 2 · response
Published 1 December 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

Update IPC statutory and mandatory training to align with revised national standards.

Verbatim wording from the response

“(Surgical ANTT) when managing surgical lines. Our Education Academy also runs an accredited surgical course for non-medical staff (nurses, midwives, and Allied Health Professionals) which includes training around line care, wound care and deteriorating patients. Furthermore, we have now updated our IPC statutory and mandatory training so that it is in line with the revised national standards.”

Source location

Response from Barts Health NHS Trust
Page 6 · response
Published 1 December 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

Implement ANTT monitoring and training across wards, with audits and a target of at least 85% compliance.

Verbatim wording from the response

“Issue | AIM | Action | Owner | Staff involved | Measure of success Line Infections | To ensure particularly long line infections are clear of all known infections | To monitor insertion and Line care on all wards - local audit Training initiated - planning OSCE several dates planned Data will be brought about how best and what to collect ANTT project to start | Ward 3E | All wards; Nutrition team | Nutrition audits IPC audits”

Source location

Response from Barts Health NHS Trust
Page 2 · response
Published 1 December 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 line insertion and care across wards, provide feedback, and continue monitoring infection-control performance.

Verbatim wording from the response

“In the summer of 2022, prior to Ms Whinney’s death, the surgical nursing leadership team implemented an improvement programme for the management of lines. This included a number of workstreams including:”

Source location

Response from Barts Health NHS Trust
Page 2 · response
Published 1 December 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 line-care, CRBSI and Surgical ANTT education for nursing, medical, surgical and other relevant staff.

Verbatim wording from the response

“In the summer of 2022, prior to Ms Whinney’s death, the surgical nursing leadership team implemented an improvement programme for the management of lines. This included a number of workstreams including:”

Source location

Response from Barts Health NHS Trust
Page 2 · response
Published 1 December 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 multidisciplinary line-infection governance through the Surgical IPC and Harm Free Care Forum and monitor its infection-reduction action plan.

Verbatim wording from the response

“The introduction of a multi-disciplinary Line Infection Meeting provided a forum to share learning across departments as well as the introduction and oversight of a robust action plan started in December 2022. This action plan continues to be monitored to this day with infection control practice being regularly audited across the wards. As a note of good practice, this meeting has now expanded to be the Surgical Infection Prevention and Control (IPC) and Harm Free Care Forum, it thus incorporates a number of other aspects that all contribute to improving our patients safety and promoting a positive experience for them whilst in our care. Below is the most recent section regarding the IPC action plan for reducing infections:”

Source location

Response from Barts Health NHS Trust
Page 2 · response
Published 1 December 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

Rewrite the ANTT policy with microbiology and IPC teams and embed it in training and competency requirements aligned with national guidelines.

Verbatim wording from the response

“The Deputy Director of the Barts Health Education Academy is currently in the process of re-writing the ANTT policy with our microbiology and Infection Prevent and Control (IPC) teams. When launched, this multi-disciplinary policy will be embedded with training and competencies that adhere to national guidelines. It is anticipated that the final version of this policy will be ready by the end of January 2024.”

Source location

Response from Barts Health NHS Trust
Page 6 · response
Published 1 December 2023

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

A comprehensive Serious Incident investigation was not considered necessary because the clinical timeline did not warrant it; events were investigated locally.

Verbatim wording from the response

“I note from the feedback from the trusts legal team, that you had been informed in November 2022 that a Serious Incident (SI) investigation was to be completed. I apologise for the error in this information, it was never our intention to investigate this through the SI process and you were misinformed about this. Our staff had correctly reported it on our incident reporting system (Datix ID 399559) noting the various line infections and it has been investigated locally through that route.”

Source location

Response from Barts Health NHS Trust
Page 1 · response
Published 1 December 2023

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.16

  1. 1

    Keep Interventional Radiology procedure-room doors closed when not in use and reinforce this through safety briefings and huddles.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 1 December 2023.
  2. 2

    Establish damp-dusting allocations and cleaning records for Interventional Radiology procedure rooms.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 1 December 2023.
  3. 3

    Improve ward dusting, storage orderliness, sharps-bin safety, and patient-area cleanliness through assigned checks, education and repeated audits.

    Stated by Barts Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 1 December 2023.
  4. 4

    Replace old or rusted Interventional Radiology trolleys and gratnells.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 1 December 2023.
  5. 5

    Use ward cleaning checklists and strengthen cleaning of clinical areas, equipment, medication areas and patient furnishings.

    Stated by Barts Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 1 December 2023.
  6. 6

    Monitor nutrition compliance, improve MUST-score performance, provide nutrition training, and introduce Symbiotix across wards.

    Stated by Barts Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 1 December 2023.
  7. 7

    Re-educate Interventional Radiology staff on bare-below-the-elbows requirements and reinforce challenge of non-compliance.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 1 December 2023.
  8. 8

    Strengthen medication-area infection controls by securing intravenous medicines, adding cleaning checks, cleaning trolleys, and assigning daily verification.

    Stated by Barts Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 1 December 2023.
  9. 9

    Maintain monthly divisional reporting to the hospital IPC Committee for oversight of hospital-acquired infections.

    Stated by Barts Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 1 December 2023.
  10. 10

    Assign responsibility for cleaning Interventional Radiology equipment and surfaces and maintain that allocation.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 1 December 2023.
  11. 11

    Replace damaged Interventional Radiology procedure-table cushions and pillows.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 1 December 2023.
  12. 12

    Allocate and record regular cleaning of Interventional Radiology equipment, using “I am clean” labels.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 1 December 2023.
  13. 13

    Reinforce bare-below-the-elbows compliance through safety briefings, staff challenge and weekly ward-manager spot checks.

    Stated by Barts Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 1 December 2023.
  14. 14

    Create and implement a protocol for managing visor scrubbing-in with IPC team input.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 1 December 2023.
  15. 15

    Relocate donning trolleys throughout Interventional Radiology laboratories and rooms and inform staff.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 1 December 2023.
  16. 16

    Reorganize Interventional Radiology equipment storage to improve access for domestic cleaning.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 1 December 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

Keep Interventional Radiology procedure-room doors closed when not in use and reinforce this through safety briefings and huddles.

Verbatim wording from the response

“Doors of the procedure rooms are kept open when not in use All doors kept closed at all times. Action mentioned in the safety briefing and morning huddle for 2 weeks. Sister IR Nursing Team All doors kept closed at all times.”

Source location

Response from Barts Health NHS Trust
Page 5 · response
Published 1 December 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

Establish damp-dusting allocations and cleaning records for Interventional Radiology procedure rooms.

Verbatim wording from the response

“Dusts observed in procedure rooms | Regular cleanliness maintained. | Regular damp dusting allocation for staff and creation of cleaning record. | IR IPCC Team | IR team | Cleanliness maintained and documented”

Source location

Response from Barts Health NHS Trust
Page 4 · response
Published 1 December 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

Improve ward dusting, storage orderliness, sharps-bin safety, and patient-area cleanliness through assigned checks, education and repeated audits.

Verbatim wording from the response

“High dust and low dust particularly in bay areas | Aim to achieve at least 90% compliance with Tendable audit. Aim to stay green for audit. | Escalated to patient ambassadors who are responsible for cleaning. Still not 100% = Discussed ways in changing the schedule - rotating with half starts at 07:00am so the whole ward is focused on 15 hours of funded cleaning is required extra on ward 3D | Ward 10e | Serco | Tendable audit results IPC quarterly audit results”

Source location

Response from Barts Health NHS Trust
Page 3 · response
Published 1 December 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

Replace old or rusted Interventional Radiology trolleys and gratnells.

Verbatim wording from the response

“Rusted trolleys/gratnells All old and rusted trolleys/gratnells replaced. Identify and replace trolleys/gratnells that will need replacing. Sister IR Nursing team All old and rusted trolleys/gratnells replaced.”

Source location

Response from Barts Health NHS Trust
Page 5 · response
Published 1 December 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

Use ward cleaning checklists and strengthen cleaning of clinical areas, equipment, medication areas and patient furnishings.

Verbatim wording from the response

“In the summer of 2022, prior to Ms Whinney’s death, the surgical nursing leadership team implemented an improvement programme for the management of lines. This included a number of workstreams including:”

Source location

Response from Barts Health NHS Trust
Page 2 · response
Published 1 December 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

Monitor nutrition compliance, improve MUST-score performance, provide nutrition training, and introduce Symbiotix across wards.

Verbatim wording from the response

“Nutrition | Review of MUST scores ensure all wards above 85% | To monitor compliance and actions across all wards Nutrition board Training MUST scores improving across all wards Symbiotix initiating on all wards - hostess will order - to look at who else needs training | Matron | All Wards; Matron | Nutrition audits IPC audits”

Source location

Response from Barts Health NHS Trust
Page 3 · response
Published 1 December 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

Re-educate Interventional Radiology staff on bare-below-the-elbows requirements and reinforce challenge of non-compliance.

Verbatim wording from the response

“Issue | Aim | Action | Owner | Staff involved | Measure of success Some staff not observing bare below the elbows. | Staff following bare the elbow protocol. | Protocol discussed in safety huddles for 2 weeks (documented in daily huddle minutes). Radiographers and Clinicians re-educated. Staff encouraged to challenge non-compliant members of team. | Sister | IR Team | IR team fully compliant.”

Source location

Response from Barts Health NHS Trust
Page 4 · response
Published 1 December 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

Strengthen medication-area infection controls by securing intravenous medicines, adding cleaning checks, cleaning trolleys, and assigning daily verification.

Verbatim wording from the response

“Medication Management | Aim to achieve at least 90% compliance with Tendable audit by IPC. Aim to stay green for audit. | Moved IV medications into the locked medication cupboard. Drug prep area and storage shelving area to be included into the daily cleaning checklist. Medication trolley to be cleaned as required and checked daily. NIC to check if daily temp record are complete on each shift. To ensure all drug trolleys are clean - rota implemented on wards Include pharmacist to this meeting | All wards | All staff | Tendable audit results IPC quarterly audit results”

Source location

Response from Barts Health NHS Trust
Page 4 · response
Published 1 December 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

Maintain monthly divisional reporting to the hospital IPC Committee for oversight of hospital-acquired infections.

Verbatim wording from the response

“The divisions continue to report progress each month to the hospitals IPC Committee chaired by the Director of Nursing (who is also the hospitals Director of Infection Prevention and Control, DIPC) and this maintains oversight of the hospital acquired infections.”

Source location

Response from Barts Health NHS Trust
Page 5 · response
Published 1 December 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

Assign responsibility for cleaning Interventional Radiology equipment and surfaces and maintain that allocation.

Verbatim wording from the response

“Task allocation for cleaning equipment and surfaces - unclear responsibilities Regular cleanliness maintained. Identification of responsibility owner and action maintained. Senior Radiographer IR Radiographers team Regular cleanliness maintained.”

Source location

Response from Barts Health NHS Trust
Page 5 · response
Published 1 December 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

Replace damaged Interventional Radiology procedure-table cushions and pillows.

Verbatim wording from the response

“Damaged procedure table cushion and pillows All damaged procedure table cushion and pillows replaced. Identify damaged procedure table cushion and pillows then replace. Senior Radiographer IR Team All damaged procedure table cushion and pillows replaced.”

Source location

Response from Barts Health NHS Trust
Page 5 · response
Published 1 December 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

Allocate and record regular cleaning of Interventional Radiology equipment, using “I am clean” labels.

Verbatim wording from the response

“Inadequate cleaning of some equipment (i.e., ultrasound machine, etc. All equipment’s cleaned on a regular basis with "I am clean labels". Creation of cleaning allocation and record for equipment’s. IR IPCC Team IR IPCC Team All equipment cleaned on a regular basis with "I am clean labels".”

Source location

Response from Barts Health NHS Trust
Page 5 · response
Published 1 December 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

Reinforce bare-below-the-elbows compliance through safety briefings, staff challenge and weekly ward-manager spot checks.

Verbatim wording from the response

“Staff compliance with bare below the elbows | Aim to achieve at least 90% compliance with Tendable audit. Minimise transmission of infection in the ward. | All staff are reminded about the uniform policy in daily safety briefing. Ward manager to do spot checks on weekly Noted during the strike the 3rd floor is very cold to bring to IPC board Compliance improving staff challenging poor practice | All wards | All Staff | Symbiotic audit results Tendable audit IPC quarterly audit results”

Source location

Response from Barts Health NHS Trust
Page 3 · response
Published 1 December 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

Create and implement a protocol for managing visor scrubbing-in with IPC team input.

Verbatim wording from the response

“Appropriate plan for management of visors scrubbing in Protocol in place and put into practice. Consult IPCC Team on creating a protocol/ management plan. Sister IR Nursing team Protocol in place and put into practice.”

Source location

Response from Barts Health NHS Trust
Page 5 · response
Published 1 December 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

Relocate donning trolleys throughout Interventional Radiology laboratories and rooms and inform staff.

Verbatim wording from the response

“Donning area prone for splash contamination Donning trolleys relocated in all rooms. Donning trolleys relocation for all labs/rooms and inform all staff. Sister IR Team Donning trolleys relocated in all rooms.”

Source location

Response from Barts Health NHS Trust
Page 5 · response
Published 1 December 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

Reorganize Interventional Radiology equipment storage to improve access for domestic cleaning.

Verbatim wording from the response

“Inappropriate and mix storage of items and equipment making it difficult to clean non-critical / low risk areas | Items stored appropriately. Access for Domestics to clean all areas. | Re-organisation of equipment’s in the non-critical / low risk areas. | IR IPCC Team | IR IPCC Team | Items stored appropriately. Access for Domestics to clean all areas.”

Source location

Response from Barts Health NHS Trust
Page 4 · response
Published 1 December 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