Moses Boardman
11 Aug 2020 · Coroner Graeme Irvine · East London
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of clear computerised record of address change
“The absence of a clear computerised record in the RLH departure .l ounge explaining the change of address.”
2. lack of safeguard for discharge to correct address
“The lack of a clear safeguard to ensure that a vulnerable patient is discharged to the correct address.”
3. failure to assess venue suitability
“The failure of RLH transport staff to properly assess the suitability of the venue that a patient is being taken to.”
4. care provider unresponsiveness to escalation
“The responsiveness of the care provider commissioned by LBTH to escalate the fact that they had been unable to reach Mr [name redacted] for his first 3 care visits.”
5. inadequate monitoring of fed at risk patients
“The proper monitoring of patients on RLH ward 14F who have been · assessed as being ''fed at risk". Specifically, why was a vulnerable patient left with unsuitable foods within his reach.”
6. failure to initiate CPR despite reversible cause
“The RLH failure to commence CPR when a potential reversible cause for collapse existed that would override the effect of the DNAR order.”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“The failure of RLH transport staff to properly assess the suitability of the venue that a patient is being taken to.”
Later report
“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.”
Responses
2020-0160-Response-from-Barts-Health-NHS-Trust_Redacted.pdf ↗· Barts Health NHS Trust
Stated action
“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.”
Stated action
“the departure lounge will now complete documentation audits in line with trust practice for clinical areas to provide assurance that this is being completed.”
Stated action
“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.”
Stated action
“As an action the Associate Director of Transport has arranged to review the current safeguarding processes in place and this process will be amended according to their findings.”
Stated action
“After the initial Serious Incident (SI) investigation we understand there was concern about Mr [name redacted] choking on fruit, therefore a second investigation was carried out to look at this particular potential incident. It's clear from staff statements that Mr [name redacted] had taken a bite out of the kiwi fruit before it was removed at 2000. At 0200 he is heard coughing and when the nurse attends she finds him unresponsive. Although he has a DNR order the cardiac arrest team is called. They arrive and”
2020-0160-Response-from-London-Borough-of-Tower-Hamlets.pdf ↗· London Borough of Tower Hamlets