Barts Health NHS Trust

“The Trust acknowledge that Mr [name redacted] family raised serious concerns in their family statement about the care provided to Mr [name redacted] during his final admission to Whipps Cross Hospital. The family concerns were investigated and responded to via the complaints process. The Trust recognise that provision of the complaint response 2 days before the inquest was unacceptable.”

“the trust will be responding to you directly on the steps they are taking locally; this includes action to help improve the awareness and care provided in the emergency department for patients with sickle cell anaemia”

“A specific induction programme has been formulated for the A&E which specifically covers themes such as the mental capacity act, contemporaneous documentation including emergency administered drugs with rationale, sedation and also escalation.”

“The speciality medicine team have a teaching programme and induction of all levels of staff on Internal Professional standards and appropriate contemporaneous documentation.”

“Teams will ensure that consultants on call confirm that they have remote access to the electronic healthcare record, this will eliminate the risk that documentation is not completed in relation to critical decisions.”

“The Trust are supportive of staff that are increasingly managing high numbers of complex and acutely unwell patients. In this case, doctors sought and were provided with advice from a consultant on call. The consultant on call will attend to perform certain procedures (in line with the Royal College of Emergency Medicine guidance).”

“The speciality medicine team have a teaching programme and induction of all levels of staff on Internal Professional standards and appropriate contemporaneous documentation.”

“WXH have very carefully considered PFDs issued by the coroner in conjunction with late submissions and the impact this has on families, HM Coroner and ensuring preparedness for inquests. Steps have been taken to ensure that specialities have early sight of inquests.”

“Staffing levels have been reviewed by the senior doctors in the divisions of medicine and surgery and are felt to be appropriate. Incidents are reviewed and feedback is listened to from junior doctors and taken into account when deciding on future staffing levels.”

“A new process has been introduced, in which contact information for on call doctors is displayed in relevant clinical areas so that there is complete clarity about who should be contacted.”

“The interaction and interface between the orthopaedic and orthogeriatric teams has been reviewed and updated, to ensure that there is no misunderstanding and that no patient who would benefit from a medical assessment is missed.”

“Computers on wheels are also available for use.”

“The Health Board is now fully reviewing the incident process to identify where it can be improved and strengthened. A workshop was held on the 23rd October 2023 to identify current issues and to begin the work of revising our process. The concerns you have identified in this notice, and in other notices, are being directly fed into this work.”

“The electronic prescribing and medicines administration system (ePMA) currently has functionality (all of which is accessible via Millennium®) to reduce harm associated with missed or late medication administration. This includes visual aids in the form of a red tile if a dose is delayed by more than 2 hours. This visual flag is available to all users. Millenium training will be updated to reflect learning from this case to ensure that multi-professional teams know how to use the flag system to”

“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”