Graham White
18 Jul 2022 · Coroner Graeme Irvine · East London
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of registry for stent patients
“Trust did not have in place a registry of those fitted with stents that would facilitate monitoring and recall of patients”
2. inability to assess risk of prior stent patients
“At the time of the inquest the Trust are unable to assess whether they have patients with stents inserted prior to May 22 who are at risk of a similar deterioration”
3. failure to identify and escalate death as serious incident
“The Trust did not successfully identify and escalate this death through its governance procedures as a serious incident for investigation until the issue was raised by the Coroner”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“The absence of a national 'safety-netting' system (stent registry), akin to that already established for ureteric stents (a web-based registry). There is no equivalent for biliary stents.”
This report
“Trust did not have in place a registry of those fitted with stents that would facilitate monitoring and recall of patients.”
Responses
2022-0218-Response-from-Barking-Havering-and-Redbridge-University-Hospitals.pdf ↗· The Barking Havering and Redbridge University NHS Trust
2022-0218-Response-from-BAUS-HSIB.pdf ↗· Department of Health and Social Care
Stated action
“We agree that ensuring patients and their GP are aware of the potential symptoms from stents, including symptoms mimicking urinary tract infection (UTI), as well as confirmed symptomatic microbiologically confirmed UTI that could be caused by a stent.”
2022-0218-Response-from-Department-of-Health-and-Social-Care-.pdf ↗· Department of Health and Social Care
Stated action
“The Care Quality Commission (CQC) inspected the Barking, Havering and Redbridge University Trust in November 2021 where the Urgent Care and Emergency Services (UEC) at the Queen's Hospital were inspected. Concerns were identified and the Trust worked with local system partners to create an action plan to address these. CQC intends to inspect the UEC at the Queen's Hospital again and will consider the Trust's response to the Coroner in these inspection plans. In the meantime, CQC will monitor the”