PFD report

Gregg O’REILLY · Prevention of Future Deaths report

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Issued 19 Jan 2014•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
2

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
16

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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

Concerns raised2

  1. Failure to record required patient observations
    Part of recurring concern: Unreliable recording of required observations in care and custody
  2. Failure to refer patients to critical care when appropriate
    Part of recurring concern: Failure to reliably refer patients to required specialist services
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.5

  1. Action

    Launch an education strategy and incorporate deteriorating-patient recognition and response into medical and nursing induction.

    Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 May 2014.
  2. Action

    Develop formal guidelines specifying when the Critical Care Outreach Team should request critical-care medical review.

    Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 May 2014.
  3. Action

    Disseminate cardiac-arrest audit findings, agree action plans and involve relevant groups in delivering recommendations.

    Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 May 2014.

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 required patient observations

Wider context from the report

“Further, although he was on two hourly observations, no record of any observation could be found between midnight on 17.01.14 and 3am on 18.01.14, when Mr O’Reilly was found to have suffered a second bleed with very low blood pressure, and a cardiac arrest call was made. ”

Is this part of a recurring concern?

Yes — Unreliable recording of required observations in care and custody.

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 refer patients to critical care when appropriate

Wider context from the report

“I heard that an opportunity was missed by the medical, ward nursing and critical care nursing outreach teams, to refer Mr O’Reilly to critical care, certainly by 17.01.14. It is unclear whether that would have changed the outcome for him, but it meant that he was not offered optimal care. Given the number of staff who could have made such a referral, it seems that this issue goes further than individual error or lack of understanding. I appreciate that also makes it a big issue to tackle. ”

Is this part of a recurring concern?

Yes — Failure to reliably refer patients to required specialist services.

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

Launch an education strategy and incorporate deteriorating-patient recognition and response into medical and nursing induction.

Verbatim wording from the response

“10. Launch an Education Strategy to ensure all staff can identify a sick and deteriorating patient and can escalate concerns. The Trust medical and nursing Induction Programmes to incorporate a briefing on ‘Recognising and Responding to the Deteriorating Patient.’”

Source location

2014-0221-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 19 May 2014

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

Develop formal guidelines specifying when the Critical Care Outreach Team should request critical-care medical review.

Verbatim wording from the response

“5. The Critical Care Outreach Team (CCOT) and the consultant intensivists to develop formal guidelines, outlining when CCOT should request a critical care medical review.”

Source location

2014-0221-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 19 May 2014

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

Disseminate cardiac-arrest audit findings, agree action plans and involve relevant groups in delivering recommendations.

Verbatim wording from the response

“11. The Trust is planning an "all site" Cardiac Arrest Call Audit in July 2014 to determine what factors pre-empted the call and to look at whether appropriate care was taking place prior to the arrest. Ensure the findings are widely disseminated, action plans agreed, and all key groups mentioned above are involved in delivering the key recommendations.”

Source location

2014-0221-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 19 May 2014

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 the transition to electronic patient records and register and mitigate risks from the interim hybrid system.

Verbatim wording from the response

“3. Ensure the transition period from a paper based system to the full electronic patient record is as short as possible and ensure the risks of the hybrid system are on the Risk Register and appropriate mitigation is in place.”

Source location

2014-0221-Response-by-Barts-Health-NHS-Trust
Page 1 · response
Published 19 May 2014

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 an all-site cardiac-arrest call audit examining pre-arrest factors and care provided before arrests.

Verbatim wording from the response

“11. The Trust is planning an "all site" Cardiac Arrest Call Audit in July 2014 to determine what factors pre-empted the call and to look at whether appropriate care was taking place prior to the arrest. Ensure the findings are widely disseminated, action plans agreed, and all key groups mentioned above are involved in delivering the key recommendations.”

Source location

2014-0221-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 19 May 2014

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.11

  1. 1

    Share the investigation outcome with relevant Trust medical and nursing staff.

    Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 May 2014.
  2. 2

    Explore an electronic-record red flag incorporating multiprofessional contacts for chronically ill patients with complex care needs.

    Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 May 2014.
  3. 3

    Require clinical teams to conduct morbidity and mortality reviews and escalate suspected preventable deaths with serious-incident documentation.

    Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 May 2014.
  4. 4

    Establish case review meetings for concerning chronically ill patients involving all relevant care teams.

    Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 May 2014.
  5. 5

    Audit the effectiveness of the changes regularly.

    Stated by Barts Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 May 2014.
  6. 6

    Revamp the Managing the Acutely Ill Patient Group by expanding membership, senior-clinician participation, objectives and timelines.

    Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 May 2014.
  7. 7

    Consider wider learning from the investigation and determine appropriate changes.

    Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 May 2014.
  8. 8

    Include a patient or public representative on the Managing the Acutely Ill Patient Group forum.

    Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 May 2014.
  9. 9

    Re-establish the Critical Care Board using agreed terms of reference, membership and chair arrangements.

    Stated by Barts Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 May 2014.
  10. 10

    Recruit a Band 7 Sister to provide senior leadership on the relevant ward.

    Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 May 2014.
  11. 11

    Strengthen links between the Managing the Acutely Ill Patient Group and the Care Quality Collaborative Deteriorating Patient Group.

    Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 May 2014.

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 the investigation outcome with relevant Trust medical and nursing staff.

Verbatim wording from the response

“We have taken this as an opportunity to review our processes to enhance future care. The outcome of the investigation will be shared with all relevant Trust medical and nursing staff to ensure that these changes are put into practice. The effectiveness of the changes will be subject to regular audit.”

Source location

2014-0221-Response-by-Barts-Health-NHS-Trust
Page 3 · response
Published 19 May 2014

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

Explore an electronic-record red flag incorporating multiprofessional contacts for chronically ill patients with complex care needs.

Verbatim wording from the response

“4. Explore the usage of an electronic patient record red flag to identify chronically ill patients who have complex care needs and require frequent admissions to hospital. This would involve the key contacts from the multi-professional teams being incorporated into this system to expedite care and ensure continuity for the patient and the family.”

Source location

2014-0221-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 19 May 2014

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Require clinical teams to conduct morbidity and mortality reviews and escalate suspected preventable deaths with serious-incident documentation.

Verbatim wording from the response

“9. Ensure each clinical team conducts a Morbidity and Mortality review, ideally using an agreed Trust proforma for all patients who die in hospital. Any suspected preventable death identified to be escalated to the Mortality Group and a Serious Incident proforma raised.”

Source location

2014-0221-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 19 May 2014

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 case review meetings for concerning chronically ill patients involving all relevant care teams.

Verbatim wording from the response

“6. Chronically sick patients who are causing concern should have a “Case Review Meeting” which should involve all relevant teams involved in the care to agree and implement the overall management plan.”

Source location

2014-0221-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 19 May 2014

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 the effectiveness of the changes regularly.

Verbatim wording from the response

“We have taken this as an opportunity to review our processes to enhance future care. The outcome of the investigation will be shared with all relevant Trust medical and nursing staff to ensure that these changes are put into practice. The effectiveness of the changes will be subject to regular audit.”

Source location

2014-0221-Response-by-Barts-Health-NHS-Trust
Page 3 · response
Published 19 May 2014

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

Revamp the Managing the Acutely Ill Patient Group by expanding membership, senior-clinician participation, objectives and timelines.

Verbatim wording from the response

“7. Managing the Acutely Ill Patient Group (MAIPG) to be revamped, by expanding the membership, ensuring greater participation of senior clinicians from all Clinical Academic Groups, setting clear objectives with timelines, to address the most important issues. This group has forged strategic links with the Trust Quality Group and the new Mortality Review Board to ensure greater executive awareness and support. Strengthening the links between MAIPG and the Care Quality Collaborative – Deteriorating Patient Group.”

Source location

2014-0221-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 19 May 2014

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 wider learning from the investigation and determine appropriate changes.

Verbatim wording from the response

“1. The Trust Executive Team to consider the wider learning points from this review and instigate changes as appropriate.”

Source location

2014-0221-Response-by-Barts-Health-NHS-Trust
Page 1 · response
Published 19 May 2014

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

Include a patient or public representative on the Managing the Acutely Ill Patient Group forum.

Verbatim wording from the response

“8. In line with the Berwick Report 2013 the MAIPG to have a patient or public representative to sit on the forum to voice concerns and challenge decision making to improve patient safety.”

Source location

2014-0221-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 19 May 2014

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-establish the Critical Care Board using agreed terms of reference, membership and chair arrangements.

Verbatim wording from the response

“12. The Trust to re-establish the Critical Care Board, as a matter of urgency. The Terms of Reference, membership and Chair have now been agreed and a provisional date set of August 2014 has been set for the first meeting.”

Source location

2014-0221-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 19 May 2014

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

Recruit a Band 7 Sister to provide senior leadership on the relevant ward.

Verbatim wording from the response

“2. The relevant ward to have a Band 7 Sister recruited as a matter of urgency given the overall acuity of this ward and the need for senior leadership locally.”

Source location

2014-0221-Response-by-Barts-Health-NHS-Trust
Page 1 · response
Published 19 May 2014

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 links between the Managing the Acutely Ill Patient Group and the Care Quality Collaborative Deteriorating Patient Group.

Verbatim wording from the response

“7. Managing the Acutely Ill Patient Group (MAIPG) to be revamped, by expanding the membership, ensuring greater participation of senior clinicians from all Clinical Academic Groups, setting clear objectives with timelines, to address the most important issues. This group has forged strategic links with the Trust Quality Group and the new Mortality Review Board to ensure greater executive awareness and support. Strengthening the links between MAIPG and the Care Quality Collaborative – Deteriorating Patient Group.”

Source location

2014-0221-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 19 May 2014

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