Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Moses Boardman · 11 Aug 2020 · Graeme Irvine, East London
“The failure of RLH transport staff to properly assess the suitability of the venue that a patient is being taken to.”
judiciary.uk/prevention-of-future-death-reports/moses-boardman
What was promised
Stated action 1 · response to Moses Boardman (11 Aug 2020) · stated timescale: none stated
“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.”
judiciary.uk/…/2020-0160-Response-from-Barts-Health-NHS-Trust_R…
Stated action 2 · response to Moses Boardman (11 Aug 2020) · stated timescale: none stated
“the departure lounge will now complete documentation audits in line with trust practice for clinical areas to provide assurance that this is being completed.”
judiciary.uk/…/2020-0160-Response-from-Barts-Health-NHS-Trust_R…
Stated action 3 · response to Moses Boardman (11 Aug 2020) · stated timescale: none stated
“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.”
judiciary.uk/…/2020-0160-Response-from-Barts-Health-NHS-Trust_R…
2 further stated actions are listed on the full chain page.
What recurred
- 23 Jul 2026 · Monica Wood · Adrian Farrow · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Moses Boardman · 11 Aug 2020
“The failure of RLH transport staff to properly assess the suitability of the venue that a patient is being taken to.”
Later · Monica Wood · 23 Jul 2026
“There appears to have been no mechanism to review the suitability of the chosen transport and crew for a patient whose condition has materially changed from the point of booking to the point of transfer.”
What happened next
No web check of the stated actions has been published for this chain.