Kashim Ali
28 Oct 2024 · Coroner Ian Potter · Inner North London
The coroner's concerns
1. NEWS2 score not escalated
“Any National Early Warning Score ('NEWS2') should always be escalated. However, during Mr [name redacted] time on Millharbour Ward he achieved a NEWS2 score on more than one occasion, which was not escalated to the nurse in charge for review.”
2. Staff inattentive during one-to-one observations
“During part of his on Millharbour Ward, Mr [name redacted] was on one-to-one observations, requiring him to always be within the sight of a dedicated member of staff. Following Mr [name redacted] death, it transpired that during this period of observations, designated members of staff were noted to preoccupied with the use of their personal mobile telephones at times, and on one occasion, the designated member of staff was sat on a chair with their back to Mr [name redacted] door.”
3. Inaccurate observation record keeping
“The Trust noted, during its own serious incident investigation, that the quality of record keeping in relation to Mr [name redacted] observations was not always accurate. Given the key role that accurate record-keeping plays in patient care within any healthcare setting, I formed the view that this also creates significant risk.”
Responses
2024-0582-Response-from-East-London-NHS-Foundation-Trust.pdf ↗· East London NHS Foundation Trust
Stated action
“The Trust has thoroughly investigated the incident and is following established disciplinary procedures for each staff member who failed to comply with the required observation standards in relation to Mr. [name redacted] care. Where evidence of non-compliance with the Trust's policies or failure to meet expected clinical standards has been identified, appropriate action is being taken in line with our disciplinary framework.”
Stated action
“the Trust has reviewed and updated its mobile phone policy to establish clear guidelines on the acceptable use of personal phones within clinical settings, with the effect that staff are completely prohibited from using personal mobile phones during shifts.”
Stated action · three months
“the frequency of visits by a lead Nurse or a Matron on night shifts has been increased to twice a month from once a month for three months. These visits are focused on maintaining high standards of care and ensuring that all clinical practices, including the monitoring of physical health observations, are being consistently followed.”