PFD report

Flora Marion BABER · Prevention of Future Deaths report

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Issued 13 Aug 2018•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.

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Concerns
10

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
29

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

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Concerns raised10

  1. Failure to provide appropriately pureed food and eating assistance
    Part of recurring concern: Inadequate provision of food for care residents
  2. Failure to provide requested toileting assistance
    Part of recurring concern: Unsafe continence care and management
  3. Delays in treating oral thrush
    Part of recurring concern: Failure to provide timely and continuous treatment for oral thrush
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.22

  1. Action

    Introduce an electronic care-plan system and update training for staff who review and update care plans.

    Stated by Central & Cecil Housing Trust (C&CStated plannedThe respondent said that this action was planned when they made their response on 24 January 2019.
  2. Action

    Add regular Quality and Compliance Manager audits to monitoring of care planning and medication administration.

    Stated by Central & Cecil Housing Trust (C&CStated completedThe respondent said that this action was complete when they made their response on 24 January 2019.
  3. Action

    Review and further develop medication training with the Quality and Compliance Manager, Clinical Services Manager and Director of Workplace and Culture.

    Stated by Central & Cecil Housing Trust (C&CStated in progressThe respondent said that this action was in progress when they made their response on 24 January 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.8

  1. Position

    GPs, treating doctors and hospitals must provide official clinical advice before medication allergies or changes can be recorded and communicated to pharmacists.

    Stated by Central & Cecil Housing Trust (C&CRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 appropriately pureed food and eating assistance

Wider context from the report

“1. Whilst record keeping showed Dr Baber as having been given appropriate food and drink whilst on the ward in hospital, I heard that sometimes her nearest fluid was out of her reach on a bedside table too far from the bed. Also, she did not always receive appropriately pureed food or the assistance that she needed to eat. ”

Is this part of a recurring concern?

Yes — Inadequate provision of food for care residents.

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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 provide requested toileting assistance

Wider context from the report

“4. Dr Baber was noted in the medical records as being doubly incontinent. However, family members told me that she was not incontinent. Rather, when she asked for assistance to go to the toilet or to use a bedpan (she had poor mobility), a healthcare assistant told her that staff were busy, she was wearing an incontinence pad, and she should use that instead. I was shocked to hear this. ”

Is this part of a recurring concern?

Yes — Unsafe continence care and management.

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

Delays in treating oral thrush

Wider context from the report

“2. There was a delay in referring Dr Baber to the speech and language team and in treating her oral thrush. Most significantly, I heard evidence that it was only when family members pointed out a problem such as pain on swallowing, that staff acted to deal with this. ”

Is this part of a recurring concern?

Yes — Failure to provide timely and continuous treatment for oral thrush.

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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 of allocated ward staff to remain awake and attentive

Wider context from the report

“3. Family members told me that at one point, they found the member of staff allocated to Dr Baber’s bay sitting in a chair apparently asleep. ”

Is this part of a recurring concern?

Yes — Unreliable patient observation arrangements.

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

Delays in referral to the speech and language team

Wider context from the report

“2. There was a delay in referring Dr Baber to the speech and language team and in treating her oral thrush. Most significantly, I heard evidence that it was only when family members pointed out a problem such as pain on swallowing, that staff acted to deal with this. ”

Is this part of a recurring concern?

Yes — Failure to provide timely speech and language therapy for swallowing risks.

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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

Inaccurate recording of patients’ continence status

Wider context from the report

“4. Dr Baber was noted in the medical records as being doubly incontinent. However, family members told me that she was not incontinent. Rather, when she asked for assistance to go to the toilet or to use a bedpan (she had poor mobility), a healthcare assistant told her that staff were busy, she was wearing an incontinence pad, and she should use that instead. I was shocked to hear this. ”

Is this part of a recurring concern?

Yes — Unsafe continence care and management.

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 recognise opioid sensitivity when prescribing or administering opioids

Wider context from the report

“5. Dr Baber had a sensitivity to opioids, such that her family noted a direct correlation between episodes of sickness and vomiting, and the administration of opioid medication. This had been recognised and recorded during earlier admissions to the Royal Free, and family had discussed with staff at the care home. However, it was not recorded as an alert on her hospital notes, or on her general practitioner notes, or on the care home notes. At the very end of Dr Baber’s life, the benefit of pain relief was thought to outweigh the side effects of opiates, but before then her sensitivity was simply not recognised. This caused her discomfort and distress, and in another case could have fatal consequences. ”

Is this part of a recurring concern?

Yes — Failure to identify clinically significant medication risks.

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 record opioid sensitivity as an alert across care records

Wider context from the report

“5. Dr Baber had a sensitivity to opioids, such that her family noted a direct correlation between episodes of sickness and vomiting, and the administration of opioid medication. This had been recognised and recorded during earlier admissions to the Royal Free, and family had discussed with staff at the care home. However, it was not recorded as an alert on her hospital notes, or on her general practitioner notes, or on the care home notes. At the very end of Dr Baber’s life, the benefit of pain relief was thought to outweigh the side effects of opiates, but before then her sensitivity was simply not recognised. This caused her discomfort and distress, and in another case could have fatal consequences. ”

Is this part of a recurring concern?

Yes — Unreliable clinical safety-alert systems.

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 act on swallowing problems without family prompting

Wider context from the report

“2. There was a delay in referring Dr Baber to the speech and language team and in treating her oral thrush. Most significantly, I heard evidence that it was only when family members pointed out a problem such as pain on swallowing, that staff acted to deal with this. ”

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 keep drinking fluids within reach

Wider context from the report

“1. Whilst record keeping showed Dr Baber as having been given appropriate food and drink whilst on the ward in hospital, I heard that sometimes her nearest fluid was out of her reach on a bedside table too far from the bed. Also, she did not always receive appropriately pureed food or the assistance that she needed to eat. ”

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

Introduce an electronic care-plan system and update training for staff who review and update care plans.

Verbatim wording from the response

“v) It is C&C's intention to introduce an electronic care plan system, which will prompt staff to complete and update all relevant information in order to ensure that all questions are considered. C&C are in talks with potential suppliers for this new system, and we intend to introduce this, together with updating training for all staff tasked with reviewing and updating care plans, in the first quarter of next year.”

Source location

2018-0299-Response-by-CC-Housing-Trust
Page 4 · response
Published 24 January 2019

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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

Add regular Quality and Compliance Manager audits to monitoring of care planning and medication administration.

Verbatim wording from the response

“ii) In addition to regular audits carried out by our Managers, C&C's care planning and medication administration system is now also monitored through additional, regular audits carried out by our Quality and Compliance Manager.”

Source location

2018-0299-Response-by-CC-Housing-Trust
Page 5 · response
Published 24 January 2019

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 and further develop medication training with the Quality and Compliance Manager, Clinical Services Manager and Director of Workplace and Culture.

Verbatim wording from the response

“iii) The development of further medication training is currently under review with our Quality and Compliance Manager, the Clinical Services Manager and the Director of Workplace Culture. The review is due to be completed within the next 3 months. Training already includes a formal face to face training session with a comprehensive test at the end which requires a 100% pass rate. This is in addition to the online training programme”

Source location

2018-0299-Response-by-CC-Housing-Trust
Page 5 · response
Published 24 January 2019

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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

Appoint a Director of Workplace and Culture to review policies, procedures and care-staff induction, including care-plan updating.

Verbatim wording from the response

“viii) C&C have also appointed a new Director of Workplace and Culture who joined us in May 2018. She has been reviewing all the company policies and procedures and has been working with the care team, including our Quality & Compliance Manager to review staff our induction programme, including how care plans are reviewed and updated.”

Source location

2018-0299-Response-by-CC-Housing-Trust
Page 4 · response
Published 24 January 2019

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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

Brief care staff on the Coroner’s concerns and lessons learned, emphasizing communication with families and GPs and recording family-raised care concerns.

Verbatim wording from the response

“vi) On 20 August 2018, the Home Manager at Compton Lodge held a meeting with care staff to feed back the Coroner's key concerns and lessons learned. The importance of maintaining good communication with residents' families and GP's was emphasised, and staff were advised to value and record any key information or concerns raised by family members concerning a resident's needs or care.”

Source location

2018-0299-Response-by-CC-Housing-Trust
Page 6 · response
Published 24 January 2019

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 transfer checklist ensuring required medical history and care information accompanies residents between homes and hospitals.

Verbatim wording from the response

“i) To ensure that the correct documentation is sent with a resident on transfer, a check list has been introduced for C&C Care Homes since the death of Dr Baber. This is to ensure the person in charge has considered and included all the required documentation and information about the resident's medical history and needs.”

Source location

2018-0299-Response-by-CC-Housing-Trust
Page 3 · response
Published 24 January 2019

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

Appoint a nurse-qualified Clinical Services Manager to support medication audits and staff training across the homes.

Verbatim wording from the response

“vii) C&C have appointed a Clinical Services Manager who is nurse qualified and supports the Homes with medication audits and provides support and training for staff in this area.”

Source location

2018-0299-Response-by-CC-Housing-Trust
Page 4 · response
Published 24 January 2019

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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

Implement rigorous checks for maintaining current care-plan and medication records, delete obsolete electronic care-plan forms, and roll these controls out across C&C homes.

Verbatim wording from the response

“ii) Since the new Home Manager at Compton Lodge was appointed in June 2018, more rigorous checks have been put in place to ensure that the procedures for care plans and medication records to be updated and maintained are followed consistently. The storage of old care plan forms on local computers have been deleted to ensure that new and relevant information only is added to the correct, up to date version of care plan documentation for each resident. These improvements and checks have also been rolled out across our other care Homes. Moving forward, this discipline will be closely monitored by the Quality and Compliance Manager and continued improvements made across all of C&C's Homes.”

Source location

2018-0299-Response-by-CC-Housing-Trust
Page 5 · response
Published 24 January 2019

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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

Strengthen induction controls by verifying completion within a strict timeframe before staff work with residents, including care-plan documentation demonstrations.

Verbatim wording from the response

“iii) Staff completion of the full induction programme is now checked and monitored more robustly, to ensure that induction is completed within a strict timeframe and staff are not able to commence working with residents until the full induction is complete. Induction includes demonstrations for new staff on how care plan documentation is to be completed and updated.”

Source location

2018-0299-Response-by-CC-Housing-Trust
Page 5 · response
Published 24 January 2019

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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

Roll out enhanced refresher training on care-plan documentation, medication administration, and recording residents’ conditions and needs across C&C homes.

Verbatim wording from the response

“i) Since the incident at Compton Lodge, C&C have reviewed and increased the training given to staff across all of its Homes, around care plan documentation and medication administration, to ensure our residents' safety. Further training focuses upon good practice around recording and evidencing information about the residents' conditions and needs, which is discussed and demonstrated in full. This has been developed as part of staff refresher training, which is currently being rolled out throughout our Care Homes, by our Quality and Compliance Manager. This should be completed by the end of this year.”

Source location

2018-0299-Response-by-CC-Housing-Trust
Page 5 · response
Published 24 January 2019

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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

Complete the Ward 8 West healthcare assistants’ care-certificate training, including continence care.

Verbatim wording from the response

“All HCAs on Ward 8 West are working towards completion of a care certificate, which includes continence care.”

Source location

2018-0299-Response-by-Royal-Free-London-Hospitsl-NHS-Trust
Page 6 · response
Published 24 January 2019

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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

Remind staff to record and check allergies and sensitivities on every admission and discharge, including manual updates to TTA forms and drug charts.

Verbatim wording from the response

“Learning from this incident has already been shared with Pharmacy staff as well as at junior doctor prescribing teaching sessions to remind them all that allergies and sensitivities must be recorded and checked on each admission and discharge. The action to mitigate recurrence is to ensure that all staff are reminded about the need to manually record allergy/sensitives on the Freenet TTA form and drug charts.”

Source location

2018-0299-Response-by-Royal-Free-London-Hospitsl-NHS-Trust
Page 7 · response
Published 24 January 2019

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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

Develop an electronic process with IT and Cerner to record allergy information at admission and transfer it to discharge documentation, including assessing backdating options.

Verbatim wording from the response

“As a short term solution pharmacy are exploring the option with IT/Cerner to assess the best possible way to record allergies and transfer them from the point of admission (recording of allergy status on Cerner) to the automated pull of this data to the Freenet TTA. We would like to continue the current option of manual amendment of the allergy status on the Freenet TTA (as this can change through the patient’s stay in the hospital). We hope that Doctors, nurses, and pharmacists will be allowed the option to amend the allergy status in Freenet and Power chart on Cerner. There are a number of separate sets of programming codes for different templates required to implement these changes so this will take some time to embed, but the IT department have begun working on this.”

Source location

2018-0299-Response-by-Royal-Free-London-Hospitsl-NHS-Trust
Page 7 · response
Published 24 January 2019

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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

Undertake two independent unannounced spot checks of food, eating assistance, fluid access and required hydration support within the next month.

Verbatim wording from the response

“In order to assure ourselves further, two independent unannounced spot checks within the next month will be undertaken to evaluate whether patients are being given appropriate food and the necessary assistance to eat. We will also assess that fluids are within reach where appropriate and whether assistance is given if required.”

Source location

2018-0299-Response-by-Royal-Free-London-Hospitsl-NHS-Trust
Page 3 · response
Published 24 January 2019

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 EPR/EPMA functionality to populate discharge documentation with allergy status and prompt staff when allergy information is missing.

Verbatim wording from the response

“In the long term, once EPR/ EPMA (electronic prescribing system) is introduced in the trust this will automatically populate the TTA/discharge summary with the allergy status of the patient from the electronic prescription. It is expected that this will go live at Barnet and Chase Farm by the end of this year, and will be rolled out across the Royal Free site in 2019. There will be prompts on this system to alert staff when an allergy has not been recorded, and it will be more easily auditable than the current system.”

Source location

2018-0299-Response-by-Royal-Free-London-Hospitsl-NHS-Trust
Page 7 · response
Published 24 January 2019

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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

Remind Ward 8 West staff to keep patients’ tables within reach where safe, attend to hydration needs, and ensure call bells are accessible.

Verbatim wording from the response

“In response to your concerns, all issues raised by this case have been discussed with staff on Ward 8 West at the staff morning meetings, specifically on Tuesday 14 August 2018, the day after the Inquest, but also periodically since then. They have been reminded to ensure that patients’ tables are within reach where safe to do so, and to pay particular attention to hydration needs and call bells.”

Source location

2018-0299-Response-by-Royal-Free-London-Hospitsl-NHS-Trust
Page 2 · response
Published 24 January 2019

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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

Remind Ward 8 West staff to assist incontinent patients to use a commode or toilet when requested and safe.

Verbatim wording from the response

“As previously mentioned, all staff on Ward 8 West have been reminded on Tuesday 14 August 2018 and on other dates since then, that even if patients are incontinent, they should be assisted to use the commode or a toilet if they request, and if it is safe to do so. Furthermore all staff are reminded of this through actions 2, 3 and 5 on the attached action plan.”

Source location

2018-0299-Response-by-Royal-Free-London-Hospitsl-NHS-Trust
Page 6 · response
Published 24 January 2019

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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

Deliver a rolling HCA education programme covering nutrition, safe swallowing, continence care, toileting assistance and learning from the case.

Verbatim wording from the response

“Furthermore the clinical practice educator will include nutrition, safe swallow, continence care, and assistance with toileting in the HCA study days, which will be a rolling programme of education. She will also discuss this case at the study days as an opportunity to raise awareness of the patient experience. Finally, our hospital quality governance manager will present the learning from this case at the next Health Services for Elderly People specialty governance meeting.”

Source location

2018-0299-Response-by-Royal-Free-London-Hospitsl-NHS-Trust
Page 3 · response
Published 24 January 2019

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

Share learning on oral-thrush recognition and treatment with all medical staff on the ward.

Verbatim wording from the response

“However, ████████ has agreed to share the learning regarding thrush recognition and treatment with all medical staff on the ward.”

Source location

2018-0299-Response-by-Royal-Free-London-Hospitsl-NHS-Trust
Page 4 · response
Published 24 January 2019

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

Discussed appropriate coding of clinically significant opioid sensitivities in GP notes.

Verbatim wording from the response

“• 18/09/2019: Meeting ████████, ████████ (Managing partner) and ████████ (Practice Manager); to discuss how the sensitivity to opioids could have been coded appropriately in the GP notes”

Source location

2018-0299-Response-by-Adelaide-Medical-Centre
Page 1 · response
Published 24 January 2019

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

Shared learning on recording opioid sensitivities with Royal Free Hospital and Compton Lodge representatives.

Verbatim wording from the response

“• 18/09/2019: Meeting ████████████████████ (Royal Free Geriatrician), ████████ Compton Lodge Dept Care Home Manager; To share Adelaide’s learning and see how this may support recording at the Royal Free and Compton Lodge.”

Source location

2018-0299-Response-by-Adelaide-Medical-Centre
Page 1 · response
Published 24 January 2019

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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

Recorded the learning in an internal significant event and shared it with all practice clinicians, including the opioid-sensitivity alerting process.

Verbatim wording from the response

“• This reflection/learning has been captured in a significant event and shared with the other clinicians in the practice.”

Source location

2018-0299-Response-by-Adelaide-Medical-Centre
Page 2 · response
Published 24 January 2019

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

GPs, treating doctors and hospitals must provide official clinical advice before medication allergies or changes can be recorded and communicated to pharmacists.

Verbatim wording from the response

“It is important to clarify that if a resident develops an allergy to medication during their stay with us, we would expect confirmation from their GP or hospital before making any amendment to their care plan. Any information about a resident's allergy to medication would be advised in hospital discharge notes, or by the doctors in the form of an official letter. When a resident returns from hospital, a discharge letter should always be sent and a copy provided to the resident's GP to ensure that their records and those of the pharmacist are updated. Any advice concerning medication prescribed or any changes to such medication or dosage should also be recorded on their MAR chart.”

Source location

2018-0299-Response-by-CC-Housing-Trust
Page 1 · response
Published 24 January 2019

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

Care staff cannot diagnose medication allergies or sensitivities and therefore cannot record family concerns in care plans without clinical confirmation.

Verbatim wording from the response

“Any changes in the condition of the resident, including allergies, would also be noted on their care plan by the Team Leader, being informed by the hospital discharge letter and / or advice from the GP. Our residential Care Homes are not staffed by clinicians who are qualified to make diagnoses of medication allergies or sensitivities. We rely wholly on the GP, treating doctors and hospitals to communicate any medical changes and medication updates relevant to our residents.”

Source location

2018-0299-Response-by-CC-Housing-Trust
Page 1 · response
Published 24 January 2019

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 alleged sleeping incident was disputed because staff denied it and no contemporaneous reports or other evidence supported the allegation.

Verbatim wording from the response

“8 West’s Ward Manager has reviewed all the staff rotas for the Saturdays during this patient’s admission and has spoken to all staff on shift. They all deny being asleep or being aware of a colleague sleeping.”

Source location

2018-0299-Response-by-Royal-Free-London-Hospitsl-NHS-Trust
Page 4 · response
Published 24 January 2019

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 could not find evidence of a delay in referring the patient to the Speech and Language Team.

Verbatim wording from the response

“In conclusion the Trust apologises for any delay in initiating treatment for oral thrush, but we cannot find any evidence that there was a delay in referring the patient to SALT. As mentioned previously, all issues raised by this case have been discussed with staff on Ward 8 West at the staff morning meetings, specifically on Tuesday 14 August 2018, the day after the Inquest, but also periodically since then.”

Source location

2018-0299-Response-by-Royal-Free-London-Hospitsl-NHS-Trust
Page 4 · response
Published 24 January 2019

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

Continuous high-bay supervision, hourly rounding and ward-manager checks were relied on to identify and rectify inaccessible fluids or tables.

Verbatim wording from the response

“Water is normally kept on the patients’ bedside tables and individual jugs are kept topped up throughout the day by domestic staff. However, due to the patient’s subdural bleed, she was laid at a 30 degree angle throughout her final admission. Gold standard treatment and research concludes that the only position that has consistently shown to be acceptable is a head elevation of 30 degrees in patients following a brain injury. It would be expected that this would be an awkward position for any patient to be able to drink in, but the need to protect her safety in terms of the bleed was considered to be paramount. If the patient was attempting to obtain a drink and could not manage to reach it, it is expected that this would be seen and rectified by the staff member supervising the ward.”

Source location

2018-0299-Response-by-Royal-Free-London-Hospitsl-NHS-Trust
Page 2 · response
Published 24 January 2019

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

Records indicated adequate hydration, appropriate dietary provision and no evidence of dehydration apart from one slightly raised sodium level.

Verbatim wording from the response

“The patient was given a pureed diet from 13 February 2018 when it was recommended by the Speech and Language therapist following their assessment. Up until this point, the patient had been on a soft food diet and as already stated in your PFD Report, the food and fluid intake charts indicate that the patient was eating this. A soft diet consists of food such as mash, soup, custard, sauce, etc. The patient was also prescribed and administered Ensure, a nutrition supplement, from 31 January 2018. When patients are prescribed specific diets, this is included on the SBAR (daily handover sheet) so that all staff are aware on a daily basis.”

Source location

2018-0299-Response-by-Royal-Free-London-Hospitsl-NHS-Trust
Page 2 · response
Published 24 January 2019

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

Because standing was considered unsafe and no regular bedpan requests were recorded, using incontinence pads was considered most appropriate.

Verbatim wording from the response

“As the patient had been admitted with a subdural bleed, along with confusion, delirium, agitation, and visual hallucinations, it was not considered safe to encourage her to stand. The patient was assessed as being at a very high risk of falls. She was nursed in bed throughout her admission and was normally very confused. It was not felt that it would have been appropriate to assist her to a toilet, both for her own safety and for staff in terms of manual handling. However, a bed pan could have been an option. Due to the patient’s confusion, it was not felt to be appropriate to rely on her being able to call for staff when she needed the toilet, and there are no records of her regularly asking for a bedpan, so it was considered most appropriate to give her incontinence pads.”

Source location

2018-0299-Response-by-Royal-Free-London-Hospitsl-NHS-Trust
Page 6 · response
Published 24 January 2019

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

Systematic alerting of opioid sensitivities between hospital and GP practice cannot be implemented until the planned new IT system is available.

Verbatim wording from the response

“• RFH felt it was not possible to consider a more systematic alerting of sensitivities/allergies between RFH to GP practice until the new IT system (planned for ~12mths) is implemented. Therefore, no process change to be considered at this time.”

Source location

2018-0299-Response-by-Adelaide-Medical-Centre
Page 3 · response
Published 24 January 2019

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.7

  1. 1

    Require concurrent checking and updating of MAR charts and controlled-drug books during GP rounds, with managerial sign-off and staff training.

    Stated by Central & Cecil Housing Trust (C&CStated completedThe respondent said that this action was complete when they made their response on 24 January 2019.
  2. 2

    Introduce focused Quality and Compliance Manager audits of medication prescribing records and updates.

    Stated by Central & Cecil Housing Trust (C&CStated completedThe respondent said that this action was complete when they made their response on 24 January 2019.
  3. 3

    Appoint a Head of Care to review C&C documentation, policies, procedures and care-staff induction.

    Stated by Central & Cecil Housing Trust (C&CStated completedThe respondent said that this action was complete when they made their response on 24 January 2019.
  4. 4

    Establish regular group and one-to-one discussions of new practices and policy implementation within the homes.

    Stated by Central & Cecil Housing Trust (C&CStated completedThe respondent said that this action was complete when they made their response on 24 January 2019.
  5. 5

    Engage local recommended pharmacists across C&C homes to improve medication supply and disposal arrangements, with a new pharmacist appointed at Compton Lodge.

    Stated by Central & Cecil Housing Trust (C&CStated in progressThe respondent said that this action was in progress when they made their response on 24 January 2019.
  6. 6

    Introduce monthly Service Improvement Plan review meetings to monitor improvement actions and require Quality and Compliance Manager confirmation before closure.

    Stated by Central & Cecil Housing Trust (C&CStated completedThe respondent said that this action was complete when they made their response on 24 January 2019.
  7. 7

    Present learning from the case at the next Health Services for Elderly People specialty governance meeting.

    Stated by Royal Free HospitalStated plannedThe respondent said that this action was planned when they made their response on 24 January 2019.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Camden Social Services would confirm through an After Action Review that the response’s promised actions were completed.

    Stated by Royal Free HospitalRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 concurrent checking and updating of MAR charts and controlled-drug books during GP rounds, with managerial sign-off and staff training.

Verbatim wording from the response

“ii) Following Dr Baber's death, we have reviewed and tightened up medication recording practices to ensure that when the MAR charts are updated, the CD book is also checked and updated at the same time. We do this by ensuring that both the MAR charts and CD book are both taken on the weekly GP rounds, and that both are then handed over to the Manager, together with any notes made during the GP round, to be signed off. Staff are also trained to ensure that they consult both the MAR charts and CD book concurrently. The pharmacist is advised of any changes to a resident's MAR chart through the normal monthly ordering cycle of medication through the resident's prescriptions.”

Source location

2018-0299-Response-by-CC-Housing-Trust
Page 4 · response
Published 24 January 2019

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 focused Quality and Compliance Manager audits of medication prescribing records and updates.

Verbatim wording from the response

“vi) In addition to daily, weekly and annual audits of care plan documentation, more focused audits by the Quality and Compliance Manager have now been introduced to ensure that the prescription of medications is recorded and any amendments updated as necessary. This process is next due for review in December 2018.”

Source location

2018-0299-Response-by-CC-Housing-Trust
Page 4 · response
Published 24 January 2019

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

Appoint a Head of Care to review C&C documentation, policies, procedures and care-staff induction.

Verbatim wording from the response

“iv) C&C appointed a new Head of Care in September 2018. The Head of Care has completed a review of all the documentation, policies and procedures used by C&C and the induction process for care staff.”

Source location

2018-0299-Response-by-CC-Housing-Trust
Page 4 · response
Published 24 January 2019

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 regular group and one-to-one discussions of new practices and policy implementation within the homes.

Verbatim wording from the response

“v) We feel that previously the staff did not always have open and honest discussions around new practices and the implementation of these policies. This is now regularly discussed via group staff meetings and one to one supervision meetings within our Homes.”

Source location

2018-0299-Response-by-CC-Housing-Trust
Page 6 · response
Published 24 January 2019

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 local recommended pharmacists across C&C homes to improve medication supply and disposal arrangements, with a new pharmacist appointed at Compton Lodge.

Verbatim wording from the response

“iii) Following issues with the consistency of collection of unused medication by Boots, we have requested that all our home Managers across C&C look to engaging with a local pharmacist to provide our medication. We have been consulting local GP's for their recommendations in this regard, and a new pharmacist has already been appointed for Compton Lodge. We believe that using local, recommended pharmacies will ensure that we have a more complete service going forward, to include the more timely disposal of medication and to initiate include weekly audits, to support the Homes and provide further staff training as required. As confidence grows within this new relationship, we will move to external pharmacy audits on a monthly basis.”

Source location

2018-0299-Response-by-CC-Housing-Trust
Page 4 · response
Published 24 January 2019

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 monthly Service Improvement Plan review meetings to monitor improvement actions and require Quality and Compliance Manager confirmation before closure.

Verbatim wording from the response

“iv) This year we have introduced a monthly review of the SIP, which includes a meeting with the Home Manager, Quality & Compliance Manager and the Operations Manager dedicated to reviewing the progress of those service improvements detailed in the SIP and to ensure that Managers are held accountable for their implementation. Actions can only be closed down once the Quality & Compliance Manager has confirmed the action is completed. This new process is already showing improvements in service quality throughout the Care Homes in C&C. The identification and monitoring of these actions has for example, resulted in the more efficient and timely rectification of issues, such as cleaning requirements and has prompted staff to address any risks identified by residents' waterlow charts, on the same day.”

Source location

2018-0299-Response-by-CC-Housing-Trust
Page 6 · response
Published 24 January 2019

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

Present learning from the case at the next Health Services for Elderly People specialty governance meeting.

Verbatim wording from the response

“Furthermore the clinical practice educator will include nutrition, safe swallow, continence care, and assistance with toileting in the HCA study days, which will be a rolling programme of education. She will also discuss this case at the study days as an opportunity to raise awareness of the patient experience. Finally, our hospital quality governance manager will present the learning from this case at the next Health Services for Elderly People specialty governance meeting.”

Source location

2018-0299-Response-by-Royal-Free-London-Hospitsl-NHS-Trust
Page 3 · response
Published 24 January 2019

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

Camden Social Services would confirm through an After Action Review that the response’s promised actions were completed.

Verbatim wording from the response

“Following the inquest and the further concerns raised by the family of the care given to Dr Baber in the hospital, another Safeguarding conference was held with leads from Camden Social Services on the 18/09/2018, attended by the Adult Safeguarding Lead for the Trust and the Camden CCG Safeguarding Lead. The outcome from this meeting was that due to the added concerns raised, which had not been shared previously, further investigation was necessary. As the hospital was completing this response to your Prevention of Deaths Report, with all the concerns raised within it, Camden will accept this response in lieu of a Section 42 Care Act (2014) report. It was also agreed that we would partake in an ‘After Action Review’ so that Camden Social Services could confirm that all actions promised within this report were being completed.”

Source location

2018-0299-Response-by-Royal-Free-London-Hospitsl-NHS-Trust
Page 8 · response
Published 24 January 2019

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