Thomas Doyle
20 Oct 2023 · Coroner Graeme Irvine · East London
This report repeats 1 earlier warning, and was raised again 2 times later. See the linked reports.
The coroner's concerns
1. poor quality clinical records
“The trust's clinical records were of a particularly poor standard which impeded the Trust's governance investigation and the inquest investigation in determining what, if any consideration was given to the possibility that Mr [name redacted] was suffering from an infection”
2. failure to initiate sepsis diagnostic pathway
“The Trust's failure to commence a diagnostic pathway to investigate sepsis when clearly indicated on Mr [name redacted] admission, as required by both local policy and national guidance”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“Clinical records were poorly maintained, exacerbating the lapses in communication between those treating Mr [name redacted].”
This report
“The trust's clinical records were of a particularly poor standard which impeded the Trust's governance investigation and the inquest investigation in determining what, if any consideration was given to the possibility that Mr [name redacted] was suffering from an infection.”
Identical hazardConfidence 0.90 · high
This report
“The trust's clinical records were of a particularly poor standard which impeded the Trust's governance investigation and the inquest investigation”
Later report
“During Mr [name redacted] ward-based treatment on 3 & 4th May 2022 clinical records were either of a poor standard or were non-existent. The absence of clear records impeded the effective investigation”
Closely relatedConfidence 0.90 · high
This report
“The trust's clinical records were of a particularly poor standard which impeded the Trust's governance investigation and the inquest investigation in determining what, if any consideration was given to the possibility that Mr [name redacted] was suffering from an infection.”
Later report
“The investigation of this inquest was prejudiced by the absence of contemporary nursing and medical notes from various stages of [the deceased]'s treatment.”
Responses
2023-0397-Response-from-Barking-Havering-and-Redbridge-University-Hospitals-NHS-Trust-.pdf ↗· Barking
Stated action · 9 November 2023
“An Internal Alert has been shared with staff via email, Alert reference Issued Date 9 November 2023 which details good record keeping standards that should be adhered to by all staff.”
Stated action · 27 November 2023
“A video has been developed and was placed on the Trust intranet 27 November 2023 which shows - Medical Director (Patient Safety and Patient Experience), explaining the importance of good record keeping.”
Stated action · week commencing 4 December 2023
“A screen saver was agreed and appeared on all Trust computer screens week commencing 4 December 2023”
Stated action · on first day working at the Trust
“All medical staff must complete a record keeping module on the Trust BEST learning management system that allows staff to undertake e learning module on their first day working at the Trust.”
Stated action · recently
“The Trust sepsis education programme is essential for all clinical staff and has recently been updated. This is supported by additional face to face training for doctors and nurses.”
Stated action · ongoing
“The Trust has adopted the UK Sepsis Trust`s adult screening tool and the use of this is audited by the Lead Nurse for Sepsis. Audits include patients who have scored over 5 on the National Early Warning Score to ensure that Sepsis was considered. In addition, all positive blood culture cases are audited to ensure compliance with the Sepsis 6.”
2023-0397-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
Stated action
“seriously and has taken positive action to address those issues. To improve standards, an internal alert and a screen saver has been shared with staff which details good record keeping standards that should be adhered to by all staff as well as a video which has been developed with the Medical Director explaining the importance of good record keeping.”
Stated action
“1 The Trust sepsis education programme is essential for all clinical staff and has recently been updated. This is supported by additional face to face training for doctors and nurses. The Trust has adopted the UK Sepsis Trust`s adult screening tool and the use of this is audited by the Lead Nurse for Sepsis. Audits include patients who have scored over 5 on the National Early Warning Score to ensure that Sepsis was considered. In addition, all positive blood culture cases are audited to ensure”
Stated action
“Monthly audit of this takes place with the latest results showing 100% compliance of the records audited.”
Stated action
“1 The Trust sepsis education programme is essential for all clinical staff and has recently been updated. This is supported by additional face to face training for doctors and nurses. The Trust has adopted the UK Sepsis Trust`s adult screening tool and the use of this is audited by the Lead Nurse for Sepsis. Audits include patients who have scored over 5 on the National Early Warning Score to ensure that Sepsis was considered. In addition, all positive blood culture cases are audited to ensure”
Stated action · every two months
“Structured review of individual sepsis mortalities is completed internally in the Trust using defined criteria. A presentation of both external and internal reviews is made to the Sepsis Steering Committee every two months.”
Stated action
“the Trust advises that there had been a number of significant improvements since the incident occurred. Sepsis screening in the Emergency Departments has significantly improved (evidenced by audit data). The Emergency Departments now use an electronic record, Careflow, which amongst several mandatory fields has a mandatory question with respect to consideration of sepsis.”