Mr Graham Edgar White · Prevention of Future Deaths report

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Issued 18 Jul 2022•East London

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
3

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
11

Described in responses

Recipients and published responses

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 a registry of patients fitted with stents for monitoring and recall
  2. Failure to identify and escalate deaths through governance procedures as serious incidents for investigation
    Part of recurring concern: Inadequate safety incident investigationsPart of recurring concern: Unreliable formal safety-incident management processes
  3. Failure to assess whether patients with stents inserted prior to May 22 are at risk of similar deterioration

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.11

  1. Barking, Havering and Redbridge University Hospitals NHS Trust

    Progress approval of the third Urology Consultant’s job description to support additional specialist capacity.

  2. Barking, Havering and Redbridge University Hospitals NHS Trust

    Implement and operate an electronic ureteric stent register with automated population, overdue warnings and weekly monitoring.

  3. Barking, Havering and Redbridge University Hospitals NHS Trust

    Complete a retrospective review of stent insertions from 1 April 2019 to 5 August 2022 to identify missed patients and tracking gaps.

  4. Barking, Havering and Redbridge University Hospitals NHS Trust

    Introduce a lithotripsy service by commencing staff training to reduce reliance on urological stent insertion.

  5. Barking, Havering and Redbridge University Hospitals NHS Trust

    Review governance procedures for detecting potential incidents and emphasise internal incident reporting within clinical divisions.

  6. Barking, Havering and Redbridge University Hospitals NHS Trust

    Introduce incident reporting for all new inquests to formalise divisional review and identify previously unreported incidents.

  7. British Association of Urological Surgeons

    Write to the National Director for Patient Safety requesting that acute-trust medical directors ensure effective stent-tracking processes.

  8. British Association of Urological Surgeons

    Publish an updated stent patient leaflet covering symptoms, complications, intended dwell time, discharge completion fields and clinical-team contact details.

  9. British Association of Urological Surgeons

    Discuss with the Medical Device Safety Programme team how temporary-device safety will be incorporated into its work.

  10. British Association of Urological Surgeons

    Incorporate stent information into the BAUS Endourology/NHS GIRFT acute stone pathway and disseminate the pathway through BAUS professional meetings.

  11. British Association of Urological Surgeons

    Consider carrying out an audit of contemporary stent-management practices to identify tracking approaches and quantify delayed removals.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5

  1. British Association of Urological Surgeons

    Delayed stent removal should largely be addressed through individual NHS trust clinical governance systems, led by trust medical directors.

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. British Association of Urological Surgeons

    Variations in hospital IT systems make it impossible to implement a uniform NHS digital flag identifying patients with ureteric stents.

    Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
  3. British Association of Urological Surgeons

    The absence of a central NHS digital solution makes it difficult to develop consistent national standards for ureteric stent tracking.

    Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
  4. British Association of Urological Surgeons

    There is no immediate prospect of developing NHS-wide temporary-device tracing because the practical issues are considerable and commercial returns uncertain.

    Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
  5. British Association of Urological Surgeons

    The encrusted stent issue does not fully lie within BAUS’s remit or the GIRFT Urology programme.

    Outside remitThe respondent said that this matter was outside its role or authority.

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 a registry of patients fitted with stents for monitoring and recall

Wider context from the report

“1. Trust did not have in place a registry of those fitted with stents that would facilitate monitoring and recall of patients. ”

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 identify and escalate deaths through governance procedures as serious incidents for investigation

Wider context from the report

“3. The Trust did not successfully identify and escalate this death through its governance procedures as a serious incident for investigation until the issue was raised by the Coroner. ”

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

Failure to assess whether patients with stents inserted prior to May 22 are at risk of similar deterioration

Wider context from the report

“2. At the time of the inquest the Trust are unable to assess whether they have patients with stents inserted prior to May 22 who are at risk of a similar deterioration. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Progress approval of the third Urology Consultant’s job description to support additional specialist capacity.

Verbatim wording from the response

“In addition to this process there is a drive to reduce the need for stent insertion with the introduction of a lithotripsy service within BHRUT. Training is planned to start in December 2022 which should reduce the number of patients who require the insertion of urological stents and the subsequent removal or exchange. There has also been financial approval for the appointment of a third Urology Consultant to reduce the wait times for specialist urological opinion and subsequent surgical intervention. Currently the Job Description is with the Royal College for approval.”

Source location

Response from Barking, Havering and Redbridge University Hospitals
Page 2 · response
Published 27 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

Implement and operate an electronic ureteric stent register with automated population, overdue warnings and weekly monitoring.

Verbatim wording from the response

“This led to the development and implementation of a new electronic stent register which can track and warn staff of stents that are about to become overdue so appropriate actions can be taken. This stent register went live in August 2022.”

Source location

Response from Barking, Havering and Redbridge University Hospitals
Page 1 · response
Published 27 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

Complete a retrospective review of stent insertions from 1 April 2019 to 5 August 2022 to identify missed patients and tracking gaps.

Verbatim wording from the response

“To ensure there were no other patients with stents that were missed, the Trust committed to carrying out a retrospective review of all stents inserted over the preceding 3 years. This was done to ensure any patients that had been missed could be contacted and appropriate harm reviews carried out so these patients can be treated appropriately and as quickly as possible. To provide a robust mechanism of tracking and assurance a retrospective review of all stent insertions was conducted for patients attending BHRUT between 1st April 2019 and 5th August 2022.”

Source location

Response from Barking, Havering and Redbridge University Hospitals
Page 1 · response
Published 27 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

Introduce a lithotripsy service by commencing staff training to reduce reliance on urological stent insertion.

Verbatim wording from the response

“In addition to this process there is a drive to reduce the need for stent insertion with the introduction of a lithotripsy service within BHRUT. Training is planned to start in December 2022 which should reduce the number of patients who require the insertion of urological stents and the subsequent removal or exchange. There has also been financial approval for the appointment of a third Urology Consultant to reduce the wait times for specialist urological opinion and subsequent surgical intervention. Currently the Job Description is with the Royal College for approval.”

Source location

Response from Barking, Havering and Redbridge University Hospitals
Page 2 · response
Published 27 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

Review governance procedures for detecting potential incidents and emphasise internal incident reporting within clinical divisions.

Verbatim wording from the response

“In respect of the Coroner’s concern around the Trust’s delay in identifying this as a serious incident for investigation, whilst a serious incident report was completed, which has resulted in key actions and recommendations described above, that process should have commenced at an earlier stage and in accordance with the BHRUT’s own governance procedures. BHRUT has reviewed its governance procedures for the detection of potential incidents and via the Quality and Safety Team, the need to internally report incidents has been emphasised within the Divisions. In addition, BHRUT has introduced incident reporting of all new inquests to formalise divisional review, with the aim of capturing any incidents that may not have been incident reported prior to the opening of an inquest.”

Source location

Response from Barking, Havering and Redbridge University Hospitals
Page 2 · response
Published 27 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

Introduce incident reporting for all new inquests to formalise divisional review and identify previously unreported incidents.

Verbatim wording from the response

“In respect of the Coroner’s concern around the Trust’s delay in identifying this as a serious incident for investigation, whilst a serious incident report was completed, which has resulted in key actions and recommendations described above, that process should have commenced at an earlier stage and in accordance with the BHRUT’s own governance procedures. BHRUT has reviewed its governance procedures for the detection of potential incidents and via the Quality and Safety Team, the need to internally report incidents has been emphasised within the Divisions. In addition, BHRUT has introduced incident reporting of all new inquests to formalise divisional review, with the aim of capturing any incidents that may not have been incident reported prior to the opening of an inquest.”

Source location

Response from Barking, Havering and Redbridge University Hospitals
Page 2 · response
Published 27 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

Write to the National Director for Patient Safety requesting that acute-trust medical directors ensure effective stent-tracking processes.

Verbatim wording from the response

“1. Basic clinical governance responsibilities mean that there is a need for GIRFT and BAUS to flag up that the HSIB report has highlighted that patients remain at risk. GIRFT and BAUS will need to write to the National Director for Patient Safety (Aiden Fowler). The advice would be, at the very least, to request all medical directors of acute trusts to ensure that they have effective stent tracking processes in place, as detailed above.”

Source location

Response from BAUS HSIB
Page 6 · response
Published 27 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

Publish an updated stent patient leaflet covering symptoms, complications, intended dwell time, discharge completion fields and clinical-team contact details.

Verbatim wording from the response

“It is recommended that the British Association of Urological Surgeons works with the Patient Information Forum to review its stent patient information leaflet. This should include accessibility and clinical considerations, especially with regard to side effects and complications, and advice on the action to take should concerns arise.”

Source location

Response from BAUS HSIB
Page 3 · response
Published 27 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

Discuss with the Medical Device Safety Programme team how temporary-device safety will be incorporated into its work.

Verbatim wording from the response

“4. To discuss with the Medical Device Safety Programme team how temporary device safety will be incorporated into their work.”

Source location

Response from BAUS HSIB
Page 6 · response
Published 27 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

Incorporate stent information into the BAUS Endourology/NHS GIRFT acute stone pathway and disseminate the pathway through BAUS professional meetings.

Verbatim wording from the response

“It is recommended that the British Association of Urological Surgeons provides guidance for working within the stone care pathway to promote consistent advice to patients as part of discharge planning.”

Source location

Response from BAUS HSIB
Page 3 · response
Published 27 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

Consider carrying out an audit of contemporary stent-management practices to identify tracking approaches and quantify delayed removals.

Verbatim wording from the response

“2. BAUS will consider carrying out an audit of contemporary stent management practices. This could identify current approaches to stent tracking and attempt to quantify the problem of delayed removal of stents.”

Source location

Response from BAUS HSIB
Page 6 · response
Published 27 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

Delayed stent removal should largely be addressed through individual NHS trust clinical governance systems, led by trust medical directors.

Verbatim wording from the response

“Importantly, we feel that clarity is needed with regard to “ownership” of the delayed stent removal issue, in particular as to which parts of the NHS should be taking a lead going forward. As an example of this, we feel that a large part of the issue is fundamentally one that should sit within individual trust clinical governance systems and yet there are no recommendations for action by trust medical directors in the HSIB report.”

Source location

Response from BAUS HSIB
Page 6 · response
Published 27 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

Variations in hospital IT systems make it impossible to implement a uniform NHS digital flag identifying patients with ureteric stents.

Verbatim wording from the response

“It is recommended that the British Association of Urological Surgeons encourages members to include information in discharge letters and other communication sent to GPs and patients regarding patients’ stent status, potential complications and the possibility of a retained stent.”

Source location

Response from BAUS HSIB
Page 4 · response
Published 27 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 absence of a central NHS digital solution makes it difficult to develop consistent national standards for ureteric stent tracking.

Verbatim wording from the response

“It is recommended that the British Association of Urological Surgeons, in collaboration with other relevant specialties (such as the Royal College of Radiologists and British Transplant Society), develops national standards which support electronic and paper-based systems for stent logging/tracking. These standards should include guidance on monitoring and human oversight.”

Source location

Response from BAUS HSIB
Page 2 · response
Published 27 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

There is no immediate prospect of developing NHS-wide temporary-device tracing because the practical issues are considerable and commercial returns uncertain.

Verbatim wording from the response

“The NHS Summary Care Records (SCR) system is being developed to allow for specific patient groups to be flagged. It may be beneficial for the British Association of Urological Surgeons to liaise with NHSX should opportunities arise in the future to use SCR to flag patients with ureteric stents to aid communication with primary/urgent care services.”

Source location

Response from BAUS HSIB
Page 5 · response
Published 27 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 encrusted stent issue does not fully lie within BAUS’s remit or the GIRFT Urology programme.

Verbatim wording from the response

“Conclusions”

Source location

Response from BAUS HSIB
Page 6 · response
Published 27 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