Elvon Morton
13 May 2024 · Coroner Graeme Irvine · East London
This report repeats 2 earlier warnings, and was raised again 3 times later. See the linked reports.
The coroner's concerns
1. inadequate documentation of care
“Documentation of key stages in Mr [name redacted] care was poor or non-existent. Critical decisions on; mental capacity, best interests, the choice of sedation, the amount of drug administered, the method of administration and the timing of administration were not clearly recorded.”
2. flawed sedation decision
“The decision to sedate Mr [name redacted] was flawed. The lack of contemporary documentation impeded an effective coronial investigation and review of that clinical decision.”
3. governance failure in incident identification
“A failure in governance at the Trust meant that this case was not identified as a serious incident. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice”
4. inadequate incident reporting and review systems
“the trust's Datix incident reporting system, morbidity and mortality meeting process and SIRMAP procedure were inadequate. Each structure was siloed from the other, leading to inconsistent findings.”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“It seems clear that a decision was made to transfer Mrs [name redacted] from ITU on 27 November 2014. There remains the potential that this decision was made by non-clinical staff.”
This report
“The decision to sedate Mr [name redacted] was flawed. The lack of contemporary documentation impeded an effective coronial investigation and review of that clinical decision.”
Identical hazardConfidence 0.90 · high
Earlier report
“The poor quality of recording clinical records impeded the Trust's governance processes, in that the author of a serious incident investigation was unable to rely on clear evidence”
This report
“The lack of contemporary documentation impeded an effective coronial investigation and review of that clinical decision.”
Closely relatedConfidence 0.90 · high
This report
“In this case the trust's Datix incident reporting system, morbidity and mortality meeting process and SIRMAP procedure were inadequate. Each structure was siloed from the other, leading to inconsistent findings.”
Later report
“In this case the trust's Datix incident reporting system, morbidity and mortality meeting process and PSIRF procedure were inadequate.”
Closely relatedConfidence 0.90 · high
This report
“A failure in governance at the Trust meant that this case was not identified as a serious incident. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice”
Later report
“A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice”
Identical hazardConfidence 0.96 · high
This report
“A failure in governance at the Trust meant that this case was not identified as a serious incident.”
Later report
“A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework.”
Responses
2024-0258-Response-from-Barts-Health.pdf ↗· Barts Health NHS Trust
Stated action
“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.”
Stated action
“The speciality medicine team have a teaching programme and induction of all levels of staff on Internal Professional standards and appropriate contemporaneous documentation.”
Stated action
“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.”
Stated action
“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).”
Stated action
“The speciality medicine team have a teaching programme and induction of all levels of staff on Internal Professional standards and appropriate contemporaneous documentation.”
Stated action
“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.”
2024-0258-Response-from-DHSC.pdf ↗· Barts Health NHS Trust