Barts Health

“We have asked the ward matron to speak to her staff to remind them of the importance of accurately changing patient details and the consequences of not doing so.”

“the Trust is implementing a revised early warning score National Early Warning Score (NEWS) and Chronic Respiratory Early Warning Score (CREWS) which once implemented is expected to improve compliance with contacting and escalating assistance with deteriorating patients. This is being implemented at Newham University Hospital imminently, as well as across the Trust.”

“Newham University Hospital has been awarded funding to implement a vital signs monitoring process known as Vitalslink which will transmit clinical observations to the Electronic Patient Record (EPR) by WI-FI and give real-time feedback to the clinician regarding at risk status and the appropriate action to take. This is currently being piloted at Newham University Hospital with wider roll-out planned once the pilot is approved.”

“the hospital at night meeting and work is under way to improve participation by all on-call teams at night to review and discuss patients flagged as at risk at the start of the shift. This includes the introduction of afternoon safety huddles which are open to all staff and disciplines where issues can be raised and resolved.”

“The Vitalslink system will enable remote observation and alert for patients at risk - this can be used by the outreach team, ward managers and interested clinicians to rapidly detect patients even before the ward nurse has called in their concerns.”

“There is a daily consultant led trauma meeting in which all admissions, referrals, patients awaiting trauma surgery, post operative patients from the previous day and any sick patients under the care of the orthopaedic service are discussed”

“Following your Report to Prevent Future Deaths, a section has been added for signing and dating the handover sheet between the member of the team involved and this sheet is retained in the orthopaedic department for audit and transparency purposes.”

“During the investigation, senior qualified nursing staff contacted the nurse allocated to care for Mr Alli on the night of 24/15 March 2014, who confirmed that the intentional rounding did také place.”

“The Trust Executive Team to consider the wider learning points from this review and instigate changes as appropriate.”