Lack of transport suitability assessment for changing patient conditions

“The departure lounge changed its practice to ensure that the staff document in the patients electronic record in line with trust practice. Confirmation of this has been detailed within the departments most recent version of the Standard Operating Procedure (SOP). At the inquest you were shown this SOP in draft form but | can update you now to say that it has now been signed off by the Royal London Hospital's Executive Board.”

“the departure lounge will now complete documentation audits in line with trust practice for clinical areas to provide assurance that this is being completed.”

“The departure lounge clarified in their SOP that when a patient is discharged via hospital transport the Discharge Lounge staff will confirm with the Patient Transport Service driver the location and agreed destination for the patient. Any discrepancy must be escalated to the ward area for confirmation and Senior Clinical Site Manager if this discrepancy persists.”

“As an action the Associate Director of Transport has arranged to review the current safeguarding processes in place and this process will be amended according to their findings.”

“After the initial Serious Incident (SI) investigation we understand there was concern about Mr [name redacted] choking on fruit, therefore a second investigation was carried out to look at this particular potential incident. It's clear from staff statements that Mr [name redacted] had taken a bite out of the kiwi fruit before it was removed at 2000. At 0200 he is heard coughing and when the nurse attends she finds him unresponsive. Although he has a DNR order the cardiac arrest team is called. They arrive and”