Royal Free Hospital

“I intend to make a prevention of future deaths report”

“The Trust has ratified and disseminated an updated guideline for recording and escalating physiological observations in children and young people. This includes guidance for staff that the inability to obtain observations should be considered and escalated in the same way as abnormal observations.”

“A pathway for children who reattend the emergency department policy has been implemented across Royal Free London Hospital Group.”

“the Trust will be implementing the new national PEWS (Paediatric Early Warning Score) that has been mandated by NHSE as well as the updated paediatric sepsis bundle of care and alerts system. This is being integrated into the EPR and there will be a programme of staff training.”

“We will continue to be strongly supportive of this initiative and support the need for early escalation of care for those patients in whom it is not possible to undertake vital signs.”

“We have been collaborating with NHS England and the Royal College of Nursing to develop a single national PEWS for England since 2018 and are supportive of equivalent processes across the UK”

“Emergency clinicians with responsibility for the care of children receive training in how to assess risk and immediately manage children's mental health needs and support their family/carers”

“The trust emergency department electronic patient records do not show how many times a patient has presented to hospital with the same signs and symptoms during their current illness”

“we are currently reviewing our processes for recording outcomes of Mortality and Morbidity meetings, by actively exploring existing systems within the organisation.”

“Learning in relation to the increased risk of rupture in relation to multigravida women to be shared with the national maternity risk/governance managers email distribution forum. This was completed on 2 October 2020 and the email that was distributed has been embedded into the attached action plan.”

“Ensure a computer is in the delivery suite to enable contemporaneous note-keeping Please refer to the attached action plan item 2 and document, which can be summarised as follows: The Action required is for a review to take place of the workstations on wheels (WOW) on the Labour Ward to ensure that all Labour rooms possess a computer for staff use. This review was completed on 2 September 2020 and it identified that there were the appropriate number of workstation on wheels for the Labour rooms.”

“Log an incident on our Datix system to ensure the issue is investigated.”