PFD report

Rufjan BIBI · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 11 Feb 2015•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
1

Of 2 recipients

Stated actions
8

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

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

Concerns raised3

  1. Delays in consultant review for patients with impaired consciousness
    Part of recurring concern: Delays in consultant review of patients
  2. Patients being expected to obtain private nursing support to receive appropriate hospital care
  3. Failure to provide timely continence and personal care assistance
    Part of recurring concern: Unsafe continence care and management
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.4

  1. Action

    Implement intentional rounding to monitor patients’ needs and safety.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 11 February 2015.
  2. Action

    Explain the escalation policy to new trainees, including timely assessment, intervention, documentation and senior review.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 11 February 2015.
  3. Action

    Train staff to obtain prompt consultant review for acutely unwell patients or potentially dangerous injuries.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 11 February 2015.

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

  1. Position

    Private one-to-one carers are not usual practice; patients are assessed against criteria and professional judgement determines whether special care is needed.

    Stated by Barts Health 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

Delays in consultant review for patients with impaired consciousness

Wider context from the report

“3. Having been found at just before 2pm, Ms Bibi did not receive a consultant review until 7pm, and arrangements were then made for her transfer to the Royal London Hospital. During the intervening five hours, she had a Glasgow Coma Score of ten, yet no witness was able to explain the delay. ”

Is this part of a recurring concern?

Yes — Delays in consultant review of patients.

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

Patients being expected to obtain private nursing support to receive appropriate hospital care

Wider context from the report

“2. Family members were also unhappy that a nurse had told them that, if they wanted closer care for Ms Bibi, then they could engage a nurse privately to come to the hospital to look after her. If this is seriously being suggested as the way for a patient in an NHS hospital to receive appropriate care, then it is worrying indeed for all patients. If it is not seriously being suggested, then it seems unkind and unnecessary. ”

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 provide timely continence and personal care assistance

Wider context from the report

“1. Ms Bibi’s family told me at inquest that when they came to visit Ms Bibi, which they did daily, they often found her in need of changing (she was incontinent), and then had difficulty obtaining prompt nurse assistance. They even found her with faeces in her hair. Whilst this did not impact upon the outcome, it made me question the evidence I had been given about frequent nursing contact, in a way that I would not otherwise have done. (And of course, however busy staff are, it is not a situation that any of us would want for our loved ones.) ”

Is this part of a recurring concern?

Yes — Unsafe continence care and management.

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

Implement intentional rounding to monitor patients’ needs and safety.

Verbatim wording from the response

“Certain actions have already been taken. Intentional rounding has been implemented as have documentation audits as part of the Clinical Friday initiative which involves senior nurses carrying out a ward round every 1st and 3rd Fridays looking at safety and quality issues. Observations of care are also being carried out. This is an independent observation of the activity of a set team or ward area for a period of time which is then followed by a meeting between the observer and individual staff. The observation surveys a variety of things such as interactions between staff, patients and the public, telephone calls, 1:1 care and even practices such as infection prevention. The intention of the meeting afterwards is to allow the individual member of staff to reflect on their practice and on how they were perceived, allowing them to”

Source location

2015-0053-Response-by-Barts-Health-NHS-Trust
Page 1 · response
Published 11 February 2015

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

Explain the escalation policy to new trainees, including timely assessment, intervention, documentation and senior review.

Verbatim wording from the response

“████████ has also met with the new trainees who joined the department on the 01 April 2015. She explained the department’s escalation policy regarding patients on the rehabilitation site or on any of the wards, who become acutely unwell. Timely assessment and intervention with good documentation are essential in ensuring that acute serious problems are treated appropriately. Senior review should always be sought expeditiously so that on-going management can be planned. Any adverse incidents on the ward, whether resulting in harm or not, should always be discussed and documented with patients and/or relatives as appropriate. Plans for on-going care should be specified. The aim of this training to juniors is to prevent delay in care that is likely to result in harm to our patients.”

Source location

2015-0053-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 11 February 2015

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

Train staff to obtain prompt consultant review for acutely unwell patients or potentially dangerous injuries.

Verbatim wording from the response

“The delay in obtaining a consultant review is not usual practice and should not have happened. The member of staff involved has been given training about obtaining a consultant review when a patient is acutely unwell or suffers a potentially dangerous injury. The doctor will also reflect on this incident in their portfolio.”

Source location

2015-0053-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 11 February 2015

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

Carry out independent observations of care followed by reflective feedback with staff.

Verbatim wording from the response

“Certain actions have already been taken. Intentional rounding has been implemented as have documentation audits as part of the Clinical Friday initiative which involves senior nurses carrying out a ward round every 1st and 3rd Fridays looking at safety and quality issues. Observations of care are also being carried out. This is an independent observation of the activity of a set team or ward area for a period of time which is then followed by a meeting between the observer and individual staff. The observation surveys a variety of things such as interactions between staff, patients and the public, telephone calls, 1:1 care and even practices such as infection prevention. The intention of the meeting afterwards is to allow the individual member of staff to reflect on their practice and on how they were perceived, allowing them to”

Source location

2015-0053-Response-by-Barts-Health-NHS-Trust
Page 1 · response
Published 11 February 2015

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

Private one-to-one carers are not usual practice; patients are assessed against criteria and professional judgement determines whether special care is needed.

Verbatim wording from the response

“This was also discussed at the Local Resolution Meeting held between Trust staff and Mrs Bibi’s family. Apologies were made; however, as there was communication issues between Trust staff and the family, the Trust did feel that this was very unlikely to have been said. It is not usual practice to have private 1:1 carers and it is not an option at present. This would offer. All patients are assessed on admission and regularly reassessed throughout their stay. Mrs Bibi did not meet the Trusts criteria for 1:1 nursing and the staff caring for her had the time used professional judgement to determine if special care was needed for her outside of the written criteria.”

Source location

2015-0053-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 11 February 2015

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 Trust stated that medical review and appropriate post-fall checks occurred soon after the fall, contrary to the reported five-hour delay.

Verbatim wording from the response

“This also was discussed at the Local Resolution Meeting and an apology made to the family. The consultant in charge, doctor ████████, has spoken to the junior doctor who was assigned to the ward at that time. They remember assessing the patient but did not remember documenting the assessment. The medical review was undertaken very soon after the fall as the Medical Team were on the ward when the fall occurred. Nursing documentation supports that a review and appropriate checks were instigated as per Barts Health Post-Falls procedures.”

Source location

2015-0053-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 11 February 2015

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 Trust considered it very unlikely that staff told the family to privately engage a one-to-one nurse.

Verbatim wording from the response

“This was also discussed at the Local Resolution Meeting held between Trust staff and Mrs Bibi’s family. Apologies were made; however, as there was communication issues between Trust staff and the family, the Trust did feel that this was very unlikely to have been said. It is not usual practice to have private 1:1 carers and it is not an option at present. This would offer. All patients are assessed on admission and regularly reassessed throughout their stay. Mrs Bibi did not meet the Trusts criteria for 1:1 nursing and the staff caring for her had the time used professional judgement to determine if special care was needed for her outside of the written criteria.”

Source location

2015-0053-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 11 February 2015

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.4

  1. 1

    Provide Band 7 ward-manager supervisory support for junior staff on clinical issues.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 11 February 2015.
  2. 2

    Provide staff training through the Older Peoples Education Programme.

    Stated by Barts Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 February 2015.
  3. 3

    Report the Coroner’s findings to the department at its next meeting.

    Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 11 February 2015.
  4. 4

    Conduct Clinical Friday senior ward rounds and documentation audits focused on safety and quality.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 11 February 2015.

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 Band 7 ward-manager supervisory support for junior staff on clinical issues.

Verbatim wording from the response

“think about how they would act if they were to encounter the same scenario a second time. Training to staff is being provided as part of the Older Peoples Education Programme. There is also a Band 7 Ward Manager Supervisory role whereby a Band 7 if possible has a reduced patient workload allowing them to offer support and guidance to more junior staff on a range of clinical issues.”

Source location

2015-0053-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 11 February 2015

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 staff training through the Older Peoples Education Programme.

Verbatim wording from the response

“Certain actions have already been taken. Intentional rounding has been implemented as have documentation audits as part of the Clinical Friday initiative which involves senior nurses carrying out a ward round every 1st and 3rd Fridays looking at safety and quality issues. Observations of care are also being carried out. This is an independent observation of the activity of a set team or ward area for a period of time which is then followed by a meeting between the observer and individual staff. The observation surveys a variety of things such as interactions between staff, patients and the public, telephone calls, 1:1 care and even practices such as infection prevention. The intention of the meeting afterwards is to allow the individual member of staff to reflect on their practice and on how they were perceived, allowing them to”

Source location

2015-0053-Response-by-Barts-Health-NHS-Trust
Page 1 · response
Published 11 February 2015

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 the Coroner’s findings to the department at its next meeting.

Verbatim wording from the response

“████████ has also discussed Mrs Bibi’s case at one of the departmental morbidity and mortality meetings prior to the Inquest hearing, the Coroner’s findings will be reported back to the department at the next meeting.”

Source location

2015-0053-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 11 February 2015

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 Clinical Friday senior ward rounds and documentation audits focused on safety and quality.

Verbatim wording from the response

“Certain actions have already been taken. Intentional rounding has been implemented as have documentation audits as part of the Clinical Friday initiative which involves senior nurses carrying out a ward round every 1st and 3rd Fridays looking at safety and quality issues. Observations of care are also being carried out. This is an independent observation of the activity of a set team or ward area for a period of time which is then followed by a meeting between the observer and individual staff. The observation surveys a variety of things such as interactions between staff, patients and the public, telephone calls, 1:1 care and even practices such as infection prevention. The intention of the meeting afterwards is to allow the individual member of staff to reflect on their practice and on how they were perceived, allowing them to”

Source location

2015-0053-Response-by-Barts-Health-NHS-Trust
Page 1 · response
Published 11 February 2015

Open published response
Back to top

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